In 1971, Dr. Donald Wilson developed and publicized a revolutionary technique for the field of neurosurgery. Rather than creating a large opening in the skull during many of his cerebral procedures, Dr. Wilson instead made a smaller hole in the region in which he’d be working to carry out his repair. Termed the “keyhole” technique, this approach opened the door for minimally invasive surgeries, which are now the standard within neurosurgery today. Not only did this technique allow the surgeon to spend more time on the repairs at hand, but it often shortened recovery times for patients, and decreased mortality rates in more risky procedures. Advancements to endoscopy technologies in the latter half of the twentieth century only increased the efficiency of keyhole surgeries, as medical professionals no longer had to continually readjust the microscopes employed to perform their procedures, and sources of illumination of the areas were already built into endoscopes. And as endoscopic keyhole surgeries became more prevalent and developed over time, they also became more predictable and calculable through detailed reports of these procedures written by surgeons that utilized these techniques. (Ormond & Hadjipanayis, 2014, pp. 6-7)
Dimensions of Rationalization
Rationalization of a field can be determined through the identification of four dimensions: predictability, control, efficiency, and calculability. Predictability is defined as the knowledge amongst consumers that a product/service will remain of the same quality over time, and in multiple locations. Control through non-human technology are the ways in which an organization’s location is designed to encourage consumers to do what they want, so in a healthcare setting, for example, have hand sanitizer stations posted throughout a hospital to encourage patients to cleanse their hands before their appointment. Efficiency, perhaps rationalization's most prominent element, is in determining the best method of carrying out a task in the least amount of time while conserving the quality of a consumer’s care. Lastly, calculability, according to Ritzer, is the emphasis placed upon the quantitative aspects of consumer services, and how these are tracked in a business setting.
While all of these dimensions play a significant role in the transformation of neurosurgery over its conception, two of these dimensions–control and predictability–played more prominent roles in these advancements than the others. Control through nonhuman technology has significantly expanded the bounds of the neurosurgical field, especially in regard to brain-imaging machinery and treatments targeting brain tumors (Barnett, 2019). Predictability has also fostered the growth of neurosurgical procedures, due in large part to pioneering professionals in the field who kept detailed records of their procedures, which provided insight into successful techniques and poor practice. Both of these categories have fed into the development of the latter two dimensions, increasing the efficiency of these surgeries (as well as the comfort of their patients), and improving the ability of professionals in this field to achieve calculability through their work.
Origins of Neurosurgery
A broad, but crucial development in the late 1800s was the creation of modern forms of anesthesia, which not only made surgeries far less complicated but more efficient for both patient and surgeon. Beginning in the late nineteenth century, there was also a vast improvement in neuroscientists’ understanding of the brain and its various structures, and in 1886, Sir Rickman Godlee performed the first recorded successful brain tumor extraction (Ormond & Hadjipanayis, 2014). Just three years later, Victor Horsley was the first to remove a tumor from a patient’s spinal cord.
During this time frame, an important invention was also in development by William Bovie, a device involved in electrosurgery that released certain frequencies into the muscle that was capable of cutting brain tissue. The individual that popularized this device in the field of neurosurgery, however, was not Bovie himself but Harvey Cushing– considered to be the father of modern neurosurgery. Cushing is responsible for several major advancements in neurosurgery, from developing our general understanding of neural structures and their functions to pioneering many important techniques involved in tumor extraction. Cushing also undoubtedly contributed vastly to the rationalization of neurosurgery, advancing the efficiency of several procedures through more successful techniques, and improving upon predictability by reforming and documenting his surgeries and lowering mortalities amongst patients. As is observable through the mention of Bovie’s device, control through non-human technology also became more prevalent through this period, as did calculability, again, because of the more prevalent documentation of successful surgeries.
Early Complications
Some of the first complications that would arise within the field of neurosurgery came about as a result of significant experimental procedures in the first half of the twentieth century. In 1914, for example, George Heuer performed the first frontotemporal craniotomy on a patient. While this was groundbreaking for the field, the procedure also had a high level of complications and possible fatalities during its first years of use. Thus, while advancing rationalization through means of efficiency in technique, irrationality also sprung about, as did a decrease in predictability. In the following decades, proficiency in this, and similar surgeries were developed, as is characteristic of experimental practices. As understanding of how best to carry out these procedures improved, mortality rates once again lowered, and advancements in predictability and control were restored.
Transformative Inventions
Arguably the most crucial time period of development for neurosurgery was the latter half of the twentieth century. At this time, both the keyhole techniques and endoscopic procedures mentioned prior were developed and popularized. In 1967, the first CT scan (pictured on the right with inventor Dr. Godfrey Hounsfield) was developed, and four years later, the first MRI machines were as well (Injury Care Center, 2020). These advancements made patient treatment far more efficient as physicians could diagnose and determine the best course of action for a given illness/injury in a faster and more accurate manner. These inventions also expanded neurosurgeons’ reliance on non-human technology to complete their jobs.
Another crucial, and still relevant area of neurosurgery that was formed during this time was robot-assisted procedures. One of the major benefits of this form of surgery was the fact that it was minimally invasive. This also meant that patients often had shorter recovery times, and less pain as a result of their operations. As robot-assisted procedures progressed in these decades, they also became more predictable as there were certain formalities to adhere to while completing its processes as opposed to other forms of neurosurgery (Sha et al., 2014). The advancements that came as a result of robotization within neurosurgery opened the door for the even more nuanced minimally-invasive procedures of the twenty-first century, and for the further rationalization of the field.
Present State of Neurosurgery
Much of the technological advancements that have occurred since the start of the twenty-first century are simple progressions of previously developed techniques. Stereotactic radiosurgery (which primarily includes the use of either the GammaKnife or the Cyberknife) has revolutionized the treatment of neurological tumors (Barnett, 2019). Many patients now no longer have to endure craniotomies and harsher forms of radiation that significantly interfere with their quality of life. With the growing prevalence and advancement of stereotactic radiosurgical techniques, the efficiency of these processes was vastly improved, as these procedures were less time-consuming and more effective in targeting tumors. The dimension of control was also further emphasized, as these procedures were only possible with the advancement of surgical technology and techniques.
Another newer method that has grown in the past decade is that of a videomicroscopy in neurosurgery (pictured on left). This device not only allows surgeons operating to have a clearer image of a patient’s brain, but the team surrounding them to see everything that is being done during a procedure (Grady, 2018). Because of the nature of this technology, many procedures completed with a videomicroscope are more efficient in completing their targets, and more predictable in their overall success because of the heightened form of visualization for the surgeon. Control is also a heavily emphasized aspect of this surgery: this method would be impossible without the development of this device.
In regards to the overall care of patients within neurosurgery, a stronger emphasis is now being placed upon the quality of care and life for those in treatment. This is to say that the manner in which neurosurgeons define success in their procedures has transformed into a more patient-centric lens. In the past, most professionals prioritized the number of tumors they removed, and the higher survival rates of their surgeries: an individualistic approach. Now, surgeons have moved to a more collaborative method in which they hold regular discussions with a patient’s other doctors, nurses, specialists, and therapists to ensure the best quality of care from both a logistical and emotional standpoint. This has improved the efficiency and effectiveness of these procedures and has emphasized more predictability because of the open dialogue with professionals with more extensive knowledge of a patient’s background.
Future Rationalization
As has been made clear from the number of technological advancements that have defined neurosurgical practices over the past two decades, significant importance is being placed on becoming familiar with these instruments and methods during the training of residents in this area of healthcare (Barkhoudarian, 2010). Neurosurgeons simply cannot provide the best quality of care without a thorough understanding of current technological practices in the field, and consequently, this trend must continue. With the continual growth of access to medical knowledge for the general public, there has also been and will be a large population of patients that will have a better understanding of their medical conditions than their doctors. As such, there is an expanding movement amongst medical professionals to listen to and even prioritize a patient’s opinion in regards to their treatment, rather than going from what they believe would be the best form of care based on their individual understanding of the patient’s condition.
Specialization across all healthcare fields is also predicted to increase, which could make medical care more financially accessible for patients of lower socioeconomic statuses. This trend, however, cannot help reduce the incredibly large economic burdens associated with medical procedures, and the scans required for proper diagnoses. These costs, even with medical insurance, can be financially detrimental to a very large portion of Americans. Many of the movements to make healthcare more accessible across the board also ignore the massive racial disparities within the system, that manifest in both a systemic and individual manner. Because these racial disparities go unaddressed and extend past the medical field to general society, the future advancements in patient care that will take place may well be limited to only those with enough privilege to access them. Until these barriers are addressed, both the field and those that work within it will continue to perpetuate discriminatory practices against patients of different ethnic and cultural backgrounds.
Irrationalities of Advancement
The first major category of irrationalities are those concerning the assembly line model of healthcare. While treating a patient with a large team of healthcare workers that each has their designated tasks can increase the efficiency of a practice, it can also feel dehumanizing from a patient’s perspective, even if this team prioritizes quality care (Association of Psychological Science, 2012). Having an honest, and trusting connection with a patient can make a significant difference in the quality of care they are receiving (Goold, 2002). Those involved in their care can also better observe the severity of their condition and the effectiveness of their treatment. Distrust is not only conducive to a negative doctor-patient relationship, but to the inefficiency of care. Receiving medical care can already be an uncomfortable process, and without trust, administering treatment can be made even more complicated.
Some additional irrationalities could arise from standardizing the processes involved in neurosurgical procedures. Standardizing the various techniques involved in these procedures could make some surgeons’ practices more efficient. Nonetheless, this fails to acknowledge the likely sizeable portion of professionals that will be resistant to these standardized processes, and have a far longer learning curve than if they simply kept with what they preferred (Barkhoudarian). Standardization can also lead to a lack of innovation and further advancement in the field, and to the failure to personalize care based on individual patients’ needs. This would fall in line with what Ritzer would describe as homogenization, and in some cases, inefficiency.
The third, and perhaps most consequential irrationality is that of the high costs associated with neurosurgery. Scans that are needed for diagnoses of neurological conditions are expensive, and so are the machines themselves. In regards to lowering the costs of neurological procedures themselves, a cost analysis of various neurosurgeries found that even after adjusting for inflation, prices for these treatments have increased in recent years. It also found that it is often difficult for various hospital networks to compete for the best prices for these procedures, as the total cost of in-patient care is nearly impossible to predict, even for direct providers (Mooney et al., 2018). These costs are also heavily dependent on an individual patient’s insurance, and access to disposable income. As a result of these impediments to lowered surgical and hospital care costs, making these procedures more accessible while maintaining the quality of care would be difficult without changes to the inequitable nature of the healthcare system itself.
The last category of irrationalities I will mention are those related to the influences of systemic discrimination on the field because of rationalization. There was about a 9% rise in female neurosurgery residents between 2007 and 2019 (Maqsood et al., 2020). Within this same time period, and within this same study, there was only a .3% rise in Black neurosurgery residents. In 2019, Black residents only constituted 4.8% of the field (see table above). While I cannot even attempt to explore all the systemic reasons that explain these statistics, I can detail why rationalization can perpetuate these circumstances. Rationalization encourages standardization and efficiency. Because of a combination of both the systemic and individual discrimination that exists within the healthcare system, they often only encourage and standardize a certain population for the role of a neurosurgeon: a white man, and more recently, a white woman. Not only does the culture of healthcare perpetuate systemic racial discrimination because of its role as an extension of both government and society, but it actively deters Black residents from pursuing its field because of the discrimination they will face in this profession. Until these systemic barriers are resolved, neurosurgery will continue to lack diversity (and rationalization will continue to further discriminatory practices).
Conclusion
Rationalization of neurosurgery, and the healthcare field in general, is an inevitable part of our future. As such, the study of advancements that have already taken place, as well as those in development, are vital for those working within the discipline itself and for any individual or organization (including the government) that will interact with this medium. Analysis of how best to approach these rationalizations so as to maximize the positive effects they evoke for medical professionals and patients is also needed in order for ethical health care practices to be conserved.
The immense dedication and passion neurosurgeons have for the field is the reason why they now prioritize the patient’s perspective so much more, as this will lead to more efficient and effective practices, and far less dehumanization and distrust in their relationship. And while this level of communication cannot resolve every irrationality of the field, as some are inherent to the system itself rather than individual human error, preservation of a patient’s humanity, which can in part come about from communication, can resolve these barriers. This not only means discussion with patients, however, but affordable healthcare, personalized treatment plans, and greater attention to the systemic discriminatory practices of the system. Without these steps, the field simply cannot grow and rationalize without more irrationalities.
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Table 1: Maqsood, H., Younus, S., Naveed, S., Chaudhary, A., Khan, M. T., & Khosa, F. (2021). Sticky Floor, Broken Ladder, and Glass Ceiling: Gender and Racial Trends Among Neurosurgery Residents. Cureus, 13(9), e18229. https://doi.org/10.7759/cureus.18229