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Reviewed by:
  • Surgeons and the Scope
  • Catherine Curtin (bio) and Joel Howell (bio)
Surgeons and the Scope. By James R. Zetka Jr. Ithaca, N.Y.: Cornell University Press, 2003. Pp. viii+214. $29.95.

Surgeons and the Scope outlines why and when general surgeons embraced the laparoscope—a tool allowing operations through a small hole in the body—by exploring medical intraprofessional dynamics, shifts in the physician labor market, and changes in government policies toward physician training. James Zetka begins by comparing traditional "open" operative techniques for intra-abdominal surgery, such as gallbladder removal, with laparoscopic procedures. Some basic surgical principles are the same for both techniques, but laparoscopy requires substantial additional skills. Discussions of laparoscopy's technical challenges are common, but Zetka's book adds a new perspective by highlighting the cultural changes required to perform laparoscopy within the tightly constrained social context of the operating room.

Zetka uses a theoretical framework based on Charles Perrow's work on complex organizations, in which traditional surgery is classified as tightly coupled and the surgeon is the sole director. In contrast, laparoscopic surgery requires an autonomous surgical assistant (or assistants), which drastically alters the strict operating-room hierarchy. Not only does laparoscopy require reorganizing traditional surgical practices, but the new organizational structure is also primed for "normal accidents." Zetka's introductory chapters convincingly relate many disruptive challenges to the operating-room culture that accompanied the introduction of laparoscopy.

But why did general surgeons embrace this difficult new skill, especially when the traditional methods were known to be safe and effective? Zetka first focuses on changing labor divisions within the medical profession. Traditionally, "medical" fields diagnosed disease and "surgical" fields focused on treatment. Surgeons gained dominance through their early-twentieth-century successes in curing diseases, and soon became content with [End Page 690] their available practice and skill sets. During this period of surgical complacency, the precursor technology to laparoscopy, endoscopy (doing procedures similar to laparoscopy through a natural orifice, such as the mouth or anus), was being developed. While surgeons felt no need to incorporate this new diagnostic tool into their practice, another medical specialty, gastroenterology, quickly adopted and subsequently mastered endoscopy. Endoscopy gave gastroenterologists direct access to tissue throughout the gastrointestinal system; these tissues could then be examined, biopsied, or removed. Additional new devices such as video monitors helped to transform endoscopy from a purely diagnostic tool to a useful therapeutic device, one that could be used to treat diseases that had previously been solely the objects of surgical intervention. Endoscopy thus threatened surgeons' dominance in the treatment of many gastrointestinal diseases.

Surgeons and the Scope also considers governmental interventions. Zetka focuses on the growth of the National Institutes of Health (NIH) and its support of basic science. Surgeons tended to focus on clinical outcomes; they had difficulty fitting into the NIH model, and they saw their academic stature diminish. During this same period, governmental attempts to increase the physician labor supply rapidly increased the number of gastroenterologists, who boldly intruded into clinical domains previously reserved for surgeons and competed effectively for patients. Recognizing this drop in professional status and encroachment by other specialties, general surgeons feared for their survival as a specialty. These concerns spurred surgeons to embrace a difficult new technology that had the potential to protect and expand their clinical domain. Once a few entrepreneurs adopted laparoscopic tools, other surgeons followed rapidly.

This book provides an interesting exploration of the complex forces affecting the adoption of technology and a useful addition to the study of medical diffusion. Zetka does a good job of explaining for a lay audience the clinical details necessary to understand his historical and sociological analysis. Yet, while Surgeons and the Scope suggests a story about the field of surgery in general, it focuses only on general surgery, which over the course of the twentieth century has seen its domain steadily shrink. While general surgeons were resisting change, other surgeons, such as urologists and gynecologists, were much quicker to embrace laparoscopy. For a complete understanding of surgeons and the scope, one would wish for additional, comparative studies.

Catherine Curtin

At the University of Michigan, Dr. Curtin is a surgery resident and Robert Wood Johnson...

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