Perspectives and reflections on integrated digestive surgery

The history of the integration of surgery is both extensive and complex involving internecine machinations that have, over time, variously encompassed the alchemical, religious, technological and biological phases of societal development. Thus, the discipline has evolved from a mystic rite through a guild phase to its current eristic status as a therapeutic modality considered by some as an art form as opposed to a quasi-scientific endeavour of often unpredictable beneficial effect. This brief prolepsis provides an exposition of the evolution of surgeons and surgical thought proceeding from Galen in 3rd century Rome through Paré of Renaissance France, Billroth of fin de siècle Vienna, to Kocher and Whipple of Bern and New York respectively. It is apparent that in surgery, ontogeny may not readily recapitulate phylogeny and thus the need for a contemporary revaluation of integration within a novel educational nexus that encompasses the burgeoning matrix of biotechnological, ethical and fiduciary revolution is a critical requirement. Such an exercise must embody contemporary scientific and educational advance with evolving societal goals that include ethical variances, fiduciary issues and alterations in individual perceptions of life quality at both the medical and personal level. An incorporation of the basic tenets of digestive surgery as well as a delineation of its potential direction is both a vital and necessary exercise to ensure the attainment of appropriate future goals of medical, ethical, societal, scientific and educational validity. Current medical and surgical training programmes and the sub-specialization system are archaic, cumbersome, cost ineffective and, for the most part, represent endless computations and permutations of intellectually antiquated and stultifying processes designed more than a hundred years ago. As such, the maieutic skills as well as the clinical vista available for the delivery of visceral disease care bear little relation to the needs and desires of contemporary society, whether medical or lay. Indeed, the century old notion of surgery and medicine as mutually exclusive disciplines that embraced diagnosis and therapy as divergent events needs to be cast aside to facilitate the development of a new model of disease management (organ specific). Specifically, training programmes require to be shortened (educational node) and their focus dramatically reconfigured (focus module) to ensure the establishment of a unified group of specialists (cluster convergent) each interfaced in delivery of a particular skill (component specific) to the resolution of a disease affecting a specific organ system. In this fashion, a time sensitive training programme producing educationally pre-focused physicians can be implemented to deliver time effective care in a cost contained environment with maximization of expertise and comprehensive interdisciplinary integration of knowledge, experience and skill (cluster care module). As such, digestive surgery itself should cease to be regarded as an end in itself or separate entity, but rather as representative of one facet in the delivery of a multifaceted integrated health care modality focused on the digestive tract.