From time immemorial people with pain, illness or injury have sought the help of ‘others’. The ‘others’ often develop skills and knowledge which distinguish them from those seeking their help. Over time, these ‘others’ were recognized as professionals: shamans, medicine men, iatromants, and other healers1,2. The healing methods included invocation of gods or spirits, exorcism of demons, applications of heat or cold, ingestion of herbs and drugs, and application of a variety of mechanical approaches: bodily manipulations, including couching of cataracts, and removal of unwanted materials such as thorns, pus, worms or tumors. In Europe the mechanical methods, which often involved cutting, became the purview of the barbers (then barber surgeons), or their offspring, surgeons3–5. The field of surgery, as we now know it, did not stem from in academic departments, or even from the field of medical practice, but rather from artisans dealing with physical problems. All too often limitations in technology predetermined that the result would be of limited help. The great surgeon of the past was fundamentally a great craftsman.
The development of technology is one of the most characteristic features of history over the last 200 years. In this period, industry developed and the scientific method became accepted as a fundamental aspect of medical and surgical care. During the last half of the nineteenth century, the image of the physician and the surgeon started changing from that of compassionate, but often ineffective prognosticators, to effective medical scientists. Prior to that time, physicians and surgeons were revered and rewarded primarily because of their ability to support patients during difficult times; this required mastery of the craft of medicine. Of course, many individuals also benefited from the mechanical skills of surgeons, as new approaches and technologies resulted in outcomes not previously possible. Nevertheless, great procedural skill continued to be the hallmark of the great surgeon.
Craftsmanship requires knowledge of the tools and materials used in performing one’s craft. In the craft of surgery, this includes surgical instruments, anesthesia, the knowledge needed to treat injury and understanding of the techniques and indications of the types of operative procedures. The surgeon must also understand the patient’s nature, needs, wishes, and his or her unique qualities at each interaction.
The craftsman is personally involved with his or her work, and therefore always carries a subjective component. The craftsman recognizes that each created work is unique. The technologist, on the other hand, attempts to remove oneself as much as possible from one’s work. Technology implies objectivity, standardization, and uniformity of results. The results of the technologist are relatively easy to measure, and hence performance is relatively easy to evaluate. On the other hand, the quality of the craftsman’s product is quite difficult to measure. Is, for example, Cellini’s Rococco salt cellar a ‘better job’ than the Cro-Magnon man’s flint arrowhead or Calder’s starkly simple mobiles? Furthermore, the process of creating is equally as important to the craftsman as the product itself. The surgeon as a craftsman learned by apprenticeship and was taught by example. His or her major activity was demonstrating care, and the product was not ‘cure’ but ‘care’.
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