This is the last line of the Hippocratic Oath, created by the Greeks long ago. Greek physicians were required to swear upon this oath to preserve the ethical nature of medical practice. The elements of the oath are very familiar to us now; they concern maintaining patient privacy, objective judgment, a lack of corruption, etc. While the oath has been translated and edited over the years to fit the changing medical field, the core elements remain the same. Medical students swear upon this revised oath at graduation, and are expected to preserve these values in their physician care. However, what the oath entails has significantly changed with the continuous rationalization of the medical field.
For the sake of concision, we can focus on the surgical field, which has been rationalized in a manner that is almost formulaic when considering Ritzer’s four dimensions (efficiency, calculability, predictability, and control). The rationalization of the surgical field has allowed surgeons to treat more individuals across the world in shorter periods of time. Upon first thought, this seems like a net societal benefit, as a more efficient surgical field results in the net betterment of societal health; efficiency means more treatment, calculability implies cutting costs and making surgery more affordable, predictability suggests patients being able to expect the same level of treatment at every hospital, and control means that doctors and patients fall into their appropriate roles within the healthcare system. However, in reality, each of the four dimensions has a counter that forces doctors to go against their promise to serving their patients before themselves and their employers. With efficiency comes laziness and neglect to individualized details, allowing patients to fall through the cracks and expecting new technologies to cover physicians’ mistakes. Calculability can lead to emphasis shifting from patient care to hospital profit, leading to patients being treated like commodities instead of human beings. Predictability can result in an extreme level of standardization, with medical procedures being dispersed across a diverse nation with inadequate levels of patient-level personalization. Control can lead to losses of autonomy by both physicians and patients. In this paper, we will examine the magnitude at which Ritzer’s four dimensions have transformed the surgical field, and how this has changed physician practice from its birth to its current age.
. However, in reality, each of the four dimensions has a counter that forces doctors to go against their promise to serving their patients before themselves and their employers. With efficiency comes laziness and neglect to individualized details, allowing patients to fall through the cracks and expecting new technologies to cover physicians’ mistakes. Calculability can lead to emphasis shifting from patient care to hospital profit, leading to patients being treated like commodities instead of human beings. Predictability can result in an extreme level of standardization, with medical procedures being dispersed across a diverse nation with inadequate levels of patient-level personalization. Control can lead to losses of autonomy by both physicians and patients. In this paper, we will examine the magnitude at which Ritzer’s four dimensions have transformed the surgical field, and how this has changed physician practice from its birth to its current age.
Efficiency
The idea of tampering with the body in order to better human health has existed for ages. Surgery has existed centuries, with evidence dating back into the Neolithic and pre-Classical ages. It started with drilling simple holes in the brain - potentially to alleviate headaches/migraine – and there are fossils of heads that show healing after drilling as proof. In that time period, technology and general knowledge of science were extremely limited.
The lack of knowledge on anatomy and physiology was a major obstacle in the efficiency of surgical procedure; cuts were made without knowing what exactly separated diseased tissue from healthy tissue, the boundaries of different organs, or even how to cut in a manner that would allow for the body to heal properly. As more knowledge on these topics was developed and spread across the world, surgery naturally became more efficient. With more awareness of how the body functions came more speed within surgery, as surgeons were no longer taking guesses on where to cut and what part of the body needed to be treated with respect to the symptoms presented by the patient. Some of the procedures that benefitted the most from the development of anatomy education were amputations, tumor removals, and gall stone removals.
The increase in anatomical and physiological knowledge coincided with the increase of the consideration of cleanliness in surgical procedure. In 1864, Louis Pasteur revolutionized the entire surgical field with the introduction of the Germ Theory of disease – the idea that infectious disease is spread by microorganisms that enter the body as “germs.” This concept was then applied to surgery by John Lister, who hypothesized that cleaning and covering wounds after surgery would prevent post-operative infections. His work transformed surgery, as prior to this, the benefits of using surgery as medical treatment were almost entirely offset by the chance of succumbing to sepsis after the procedure. Surgical cleanliness eliminates this deficiency.
Also, this idea causes surgeons to go above and beyond and consider the idea of sterilization within the operating room. This is the main concept of aseptic surgery, which involves not just combatting infection, but preventing germ growth before it can even occur. With this came methodologies how surgeons can keep themselves, their instruments, and their patients’ wounds clean. Eventually came widespread sterilization, involving sterilizing instruments, using sterile gauze and dressings on patients, and sterilizing gloves and other surgical apparel before the surgery takes place. As a result, this has made surgery more efficient in that it prevents surgeons from having to deal with post-operative complications, which results in more materials and time being spent to correct a prior surgery.
Sterilization and overall cleanliness made the results of surgery more beneficial to the patient. However, the pain associated with surgery was still a major factor that prevented surgery from being a common option in treatment of disease. Several attempts were made over time to try and reduce patient pain during surgery, which is the general idea of anesthesia. The anesthesia was first properly attempted in surgery in 1846 by William Morton and Jon Warren. They administered gaseous diethyl ether during surgery and were successful in eliminating the pain associated surgery.
Anatomy and physiology, sterilization, and anesthesia can be considered as the points of the triangular base of surgery. Efficiency beyond these constructs is essentially betterment of those individualized constructs with the help of modern technology. One other pathway that specifically relates to anatomy and physiology is endoscopy, the concept of increasing visualization of body parts. This idea was considered long ago by Hippocrates in the 4th century B.C., as he introduced the idea of the rectal speculum.
Eventually the idea of endoscopy spread across the surgical field, and different doctors across the world developed new ways of increasing visualization. Development of new technologies gave way to laparoscopy, a surgical procedure that is simply dedicated to lower body cavity visualization. Increase in technology and efficiency meant that more time could be spent just investigating the body and increasing knowledge of what goes on internally when presented with external symptoms.
The significance of endoscopic surgery was that it paved the way for minimally invasive procedures. Visualization no longer required cutting major portions of the body and sifting through organs, resulting in more bodily trauma, longer recovery times, and more risk for infection during and post-surgery. This goes back to Hippocrates’ philosophy of doing as little harm as possible to the body, and trying to only do what is essentially necessary in surgery. This is the overarching goal of surgical procedure, and endoscopy is the tool to moving along this pathway. Furthermore, it serves as an entryway for new technologies’ introduction into surgery
. Major examples are using robotics and artificial intelligence (AI) in surgical procedure. For example, in 2020, a spinal infusion surgery used augmented reality (AR) to help surgeons visualize the 3D spinal anatomy of the patient, which enhanced “the accuracy, safety, and operating efficiency” of the surgery. Also, robotic assistance and surgery is now possible, as surgeons can use their modern endoscopic technologies to operate through a robot proxy. Beyond this, surgical robots that are built with AI technology and deep learning capabilities can both aide in surgery but also collect data from the surgery that doctors and medical specialists can use to better themselves in future surgeries, making surgery advance itself rates unseen in prior times.
Calculability
Needless to say, ancient surgeons were not concerned with the calculability of surgery – they wanted to find a solution to a problem, and naturally went with coming in physical contact with the problem. It was with time that a general concern developed for cutting the costs of surgery. In the earlier decades of surgery, when it was not nearly as effective or as common as it is now, the main goal of surgery was simply to better the health of the patient. The lack of proper tools, sterilization procedure, and anesthesia made surgery relatively cheap, so the idea of “insurance” was not even brought up at the time. However, with increasing costs of surgical care, there was an increase in the price of surgery and the burden faced by patients to get the help they need.
Each improvement in surgery can be considered as a new cost to consider (anesthetics, cleanliness, price of teaching, etc. Without insurance, hospitals would have no way of measuring the costs they were enduring in taking care of patients, how to cover them, and what to charge patients in return. This was first considered by Baylor University in Texas. The university’s hospital noticed that the hospital was essentially going into debt due to serving patients with no monetary compensation. As a result, they developed the first form of health insurance, offered to the local teacher’s union. They guaranteed teachers 21 days of completely covered hospital stay in return for a $6 annual pay. This preliminary form of insurance spread across the U.S., and was purposed with protecting both patients and hospitals from debt and bankruptcy.
A new philosophy that arose due to the introduction of insurance is the focus on quantitatively measuring quality of care. Quality of care can be broken down into different measurable factors, such as patient outcomes, patient satisfaction, clinical effectiveness, and an increase in safety positively associated with cost and time efficient surgery. Counters to quality of care are known as defects, and can be shown through surgical errors, poor outcomes, or ineffective care. The concept of measured quality of care can be broken down into “high-value care,” “low-value care,” and “no-value care.” High-value health care can be defined as high-quality outcomes that are matched with reasonable prices; low-value care increases the cost of high-value care with no increase in clinical benefit, or reduces costs with significant decrease in clinical benefit; no-value care causes harm to the patient.
Various institutions have been quantitatively measuring the value of different surgeries to compare their costs to variables such as presence of avoidable complications, clinical benefits, and preventable readmissions. Prior to these evaluations, health-benefit was calculated primarily using life-years (LY) secured by the patient due to the surgical procedure. However, the consideration of other metrics has led to more careful contemplation over what surgeries need to be revamped or removed from medical practice. The result is having insurance prices relating to surgery accurately reflect the benefits of getting this form of treatment.
Other organizations are going deeper and are trying to sort through ways to give low-to-middle-income (LMIC) hospitals a certain class of surgeries that are most suited for them, and high income (HIC) hospital surgeries that they have the resources to perform. The ideal result of increasing the calculability of surgery is having each surgery become high-value in nature, with dividing surgical responsibilities in an equitable manner that allows the most time/money-demanding surgeries to be delegated to hospitals with the most resources to perform them, and vice versa.
Predictability
When surgery was first performed, it was just a solution to a present issue, most likely discussed between a small group of people. There also was not instantaneous widespread communication like there is now, so different areas developed surgery in their own unique ways. This meant that there was on predictability in terms of what a patient (or surgeon) would expect in terms of the length of surgery, the procedure, and surgical outcomes. The predictability of medicine is shown through the development of a “standard of care” that should be met by doctors across the world. The standard of care is what most patients should expect for various surgeries that they undergo, in terms of the length in surgery, the recovery time of the surgery, and the risk of complications during and post-surgery.
Predictability of medicine began with the formalization of medical education. This dates back to the ancient Greeks’ introduction of rational inquiry to disease observation. This is where Hippocrates began his teachings of medicine, from a theoretical perspective. These forms of “medical schools” began to spread throughout the Middle Ages. While the introduction of medical schooling was monumental in that it began the process of standardizing medical procedure, the earlier schools were closer to apprenticeships than formal education. The first school that came close to developing a formal set of standards that practitioners were required to follow in order to receive some form of credentials was the university in Salerno. This led to making of more medical universities that required students to pass some form of examination or develop a dissertation in order to graduate university. When this lack in knowledge became more and more evident, the Dutch decided to incorporate a national medical practical as part of their standard medical education. Some key components of this were having students perform a physical examination and showing that they knew some of the basics of surgical procedure. This methodology was eventually employed by other universities, and soon it became an expectation for physicians to have had some form of clinical experience while in medical school.
Eventually, in America specifically, the loose ideas of what should precede and constitute medical education were tied together in the Flexner Report of 1910, which called for the standardization of medical education across different medical schools in the U.S. Soon after this more medical universities began to follow Johns Hopkins University’s example, as they had begun to increase the requirements of receiving a formal medical education in 1893 by requiring that college graduates must complete at least a year’s worth of study in the natural sciences; the university also supplemented its medical education with research and resources provided by the adjacent. From there, a general model of medical education was formed: “premedical, undergraduate, postgraduate, and continuing education.”
To go from one stage to another usually requires some form of examination and/or dissertation. For example, in the U.S., to move from undergraduate education to medical school, American medical schools required students to take either the Moss Test or the Scholastic Aptitude Test for Medical Students (SATMS). The exams signaled the introduction of standardized testing to medical school applications, and they both tested in concepts such as natural scientific knowledge, reading comprehension, reasoning and logic, and other necessary skills. These exams eventually co-evolved into the Medical College Admission Test (MCAT) which fundamentally has four different sections for testing: foundations of living systems, foundations of biological systems, foundations of behavior, and scientific inquiry and reasoning skills/critical analysis and reading skills (CARS). This exam is used as an admissions tool by essentially all modern medical schools, and reflects the basic scientific knowledge that each practicing doctor in America should have. Similarly, in order to apply for a medical license after medical school and becoming a practicing physician, students must take the United States Medical Licensing Examination (USMLE), a.k.a. the board exam. It is the only way to achieve medical licensure in the U.S. for both American and international medical.
The widespread use of standardized exams for both entry and exit of medical education is a major display of the standardization of medical practice. Doctors across the U.S. are upheld to an undeniable standard that allows for hospitals to execute a standard of care for patients. A lack of this standardization would result different techniques (proper and improper) being performed in hospitals with no reference to turn to.
Control
While the rationalization of surgery is shown to have benefits in terms of increasing calculability, predictability, and overall efficiency, the associated standardization of surgery has had restrictive effects on the autonomies of both surgeons and patients. One major demonstration of this is the increasing accountability of a surgeon to their patient. They are required to “do good” by the patient, but also listen to their patient’s requests. In moderation, this accountability can prevent violations of the rights of patients by surgeons, as in earlier times, patients had virtually no rights once they entered the operating room. This is because in earlier eras, physicians held the utmost respect from society, and essentially were viewed as masters of their field. However, as medical education was formalized and the requirements of doctoral credentialism raised, doctors began to be viewed as they were and are: imperfect workers that need to be held accountable for their actions.
One major display of physician accountability is the enforcement of informed medical consent. Informed medical consent can be defined as “a process of communication between a clinician and a patient that results in the patient’s authorization or agreement to undergo a specific medical intervention.” Informed consent protects patients from undergoing procedures that they did not agree to or did not have adequate knowledge about (usually in terms of risks of the procedure). It protects doctors from getting persecuted for following through with procedures and having suboptimal results that the patient had previously agreed was an acceptable risk of undergoing surgery. Informed consent was formally introduced by attorney Paul G. Gebhard in 1957, as he was working the medical malpractice suit Salgo v. Leland Jr. University Board of Trustees. The case involved patient Martin Salgo, who woke up paralyzed after an aortography without having been warned of paralysis being a possible risk of the procedure. Gebhard’s argument was that the surgeon not explaining the risks was form of negligence, an argument that would shape patient-doctor relationships through informed consent policies.
Another major form of control exerted upon patients and doctors is Healthcare Insurance Portability and Accountability Act (HIPAA). This act was created in an attempt to reduce the neglect and abuse of people within healthcare. The most influential portion of HIPAA is its Privacy Rule, which defined “Protected Health Information” (PHI) as “any information held by a covered entity which concerns health status, the provision of healthcare, or payment for healthcare that can be linked to an individual.” This rule mainly purposed with protecting patients from being forced to reveal certain information about themselves to invasive healthcare insurance companies. However, it also serves to prevent doctors from revealing identifying information about their patient outside of appropriate hospital settings to appropriate personnel. This side of HIPAA prevented doctors from abusing their relationship with their patient and holding them accountable to protecting their patient’s personal and medical information.
Speculation for the Future
After doing extensive research on the rationalization of the surgical field, I believe that the surgical field will only continue to be rationalized. I have come to this conclusion after reading how the surgical field is as great as it is today only because it has been rationalized. The goal of surgery is to better human health through physical and manual means. This very goal, something so simple and complete, can only be through means that are efficient, calculable, predictable, and controllable. Rationalizing the means of executing this goal means moving forward towards the ideal of being able to treat everyone’s ailments in this world. This is especially true considering that with the increase in the world’s population, surgeons will seek more ways to expand the medical field in a manner that maximizes the resources available. This is only possible through the process of rationalization, in which dimensions such as efficiency, calculability, predictability, and control will be considered. Rationalization is what allows for the spread and improvement and surgical practice across the world. Everyone in the world has needed or will need medical care in the future, and because of this, no one will want surgical care that is inefficient, too expensive, unreliable, or uncontrollable. That is why I believe there is no way that rationalization will be stopped in the future, as it only benefits us for the rationalization of surgery to continue.
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