Fission and fusion in the field of surgery.
Authors: Rhoads Jonathan E. 
Published: September 2006

Fission in the field of surgery is the process of separating new specialties. There is no foreseeable end to this process, and if one goes back to the early days of surgery in this country, it is perhaps remarkable that it has proceeded so gradually. In reviewing the history of the University of Pennsylvania School of Medicine which was the first to start in the present territory of the United States, it is of interest that the first professor of surgery, Philip Syng Physick practiced not only general surgery but also ophthalmology, urology, gynecology, otolaryngology and, indeed, virtually all branches of surgery; furthermore, he made original contributions to many of them. Ophthalmology was the first to split off following the development of the ophthalmoscope, but when the John Rhea Barton Chair of Surgery was founded in 1878 its first holder, D. Hayes Agnew, was still doing all other branches of surgery. Urology was recognized in 1886 by the appointment of Dr. J. William White. Dr. DeForest Willard became lecturer in orthopedics in 1887 and clinical professor in 1889. A clinical chair in diseases of women and children had been established as early as 1875 under William Goodell and in 1888 Howard Kelly was appointed associate professor of obstetrics jointly with Barton Cook Hirst, recognizing gynecology as such as a department. Neurosurgery was developed largely in the early years of this century and thoracic surgery came into its own more gradually in the 20th Century and is still fused with cardiac surgery. The question arises as to where we go from here. Pediatric surgery, peripheral vascular surgery seem assured of a future, whereas surgical oncology, geriatric surgery, and various other proposed fields are not yet assured of a clear status.

The benefits of this degree of specialization to the patient have been clear in most instances. In other instances there has been an awkward overlap between fields with excessive controversy. The benefits are probably most clear in the field of research where each special field gets careful attention.

Such fission has tended to weaken surgery in medical schools as compared with internal medicine, which after losing dermatology and neurology in most schools, has stayed together as a unit embracing about a dozen disciplines such as gastroenterology, allergy, diabetes, etc.; therefore, we need fusion of the common elements of the various surgical specialties for the greater strength of the whole. General surgery needs training for its residents in a number of areas which have been largely subsumed by independent special departments. The independent special departments in general seem to have stronger training programs, if a portion of the time of their residents is spent in general surgery and other fields selected for relevance to the special area; thus, plastic surgery is often a good experience for a man going into otolaryngology and vice versa. It is suggested that the occasional man aiming at an academic career may do well to take the time to complete his training in general surgery and superimpose upon this broad background the requisite training to become certified in a special field. For the larger number, however, who are interested primarily in practice a shared experience of perhaps two years during which the specialists and the general surgeons intermingle would seem to constitute a reasonable compromise.

A significant aspect of the work of the American College of Surgeons has been to hold American surgery together. Its meetings are places where one can hear not only surgical subjects discussed by representatives of several disciplines, but they are also occasions at which one meets surgeons from all of the special fields. It is easy to go to a session outside of one's own field to learn of progress in another field or to hear an old friend or colleague who has chosen a different fork of the road deliver a paper.

The American College of Surgeons has extended its effort to promote fusion beyond the field of surgery by sponsoring the formation of the Council of Medical Specialty Societies. This organization grew out of a Tri‐College Council composed of the American College of Obstetrics and Gynecology, the American College of Physicians and the American College of Surgeons. This was convened by the first of these organizations at a time when Dr. Robert Kimbrough was Director. A little later it grew to a five college council by the addition of the American Academy of Pediatrics and the American Psychiatric Association. Finally, following the publication of the Millis report, the need for a national organization to represent all of the practicing specialists in planning and regulation of graduate medical education became evident, and the five college council was given new responsibilities and expanded into the Council of Medical Specialty Societies which now includes representation from each of the major specialties. This council in turn has representatives on the Liaison Committee for Graduate Education and the Coordinating Committee for Medical Education, along with the American Medical Association, the Association of American Medical Colleges, The American Board of Medical Specialties (the examining boards) and the American Hospital Association. Because of the importance of fusion, I believe both the College and this new Council deserve your continuing support.