Surgeons and the Scope (review)

Surgery, James Zetka Jr. observes, is craft work. Unlike other handicraft workers, however, surgeons have been able to maintain occupational control by delivering quantifiable results that could not be duplicated via alternative modes of work organization. Moreover, by shifting the basis of surgical virtue from "good hands" to the cognitive bases of successful surgery - the idea of "surgical judgment" — surgeons have largely been able to defend the prestige of their handicraft, even in the face of challenges from research-oriented scientific medicine in the second half of the twentieth century. Surgeons retain unilateral control over the routines and rituals of the operating theater, where they execute virtuoso performances of handicraft skill, and they are legendary for successfully resisting workplace changes that might pose challenges to this control.

Thus, it seems unlikely that surgeons would ever willingly accept a new technology that was highly disruptive of their traditional skills. Yet this is exactly what has happened, as general abdominal surgeons have embraced laproscopic surgical techniques over the last fifteen years. In laproscopic procedures, no large incision is made; instead, surgical instruments and a tiny video camera are inserted through small ports in the abdomen. The laproscopic surgeon's only view of the operation is provided by the video monitor, and the surgeon's only access to internal tissues and organs is via instruments inserted into the abdomen but manipulated from outside. Zetka convincingly demonstrates that the transition from open surgery to laproscopic techniques required surgeons to master completely new surgical skills. Many accomplished traditional surgeons were never able to make the transition successfully. Moreover, the transition required surgeons to embrace new forms of teamwork that conflicted with strongly held notions about the independence of the individual surgeon. Zetka's descriptive account of these changes, based on direct observations of surgical practices and on interviews with 37 laproscopic surgeons, makes fascinating reading.

So does his argument about why general abdominal surgeons embraced these wrenching changes in the late 1980s and early 1990s. Moving out from his microanalysis of changes in work skills and practices in the operating theater, Zetka builds a nuanced historical argument about the relationships among occupational groups as they respond to new technologies. During the 1970s and 1980s, general surgeons faced turf challenges from academic medicine, which was producing a wide variety of effective medical treatments to problems that previously required surgery. New drugs and noninvasive therapies (such as the use of sonic waves to break up gallstones instead of extracting them surgically) were encroaching on the general abdominal surgeon's traditional preserve.

Among the most serious of these challenges was the growing practice of operative endoscopy by nonsurgeons such as gastroenterologists. Endoscopy, the insertion of a viewing instrument into a bodily orifice in order to examine the inside of the organ (for example, the large intestine), had long been used in such specialties as a diagnostic tool, but by the 1980s these practitioners had begun to perform operations endoscopically, including the removal of stones from the biliary tract. This precipitated a turf war. Abdominal surgeons argued that only they possessed skills needed to deal with the particular nature of pathology and anatomy in real time; only they could deal with complications; and only they could revert to open surgery when emergencies arose. These arguments, however, failed to wrest operative endoscopy away from the gastroenterologists — not only because the gastroenterologists had already established themselves as endoscopic practitioners, but more important, because of their upstream position in the division of labor: Family practitioners continued to refer patients to gastroenterologists for operative endoscopies, and the gastroenterologists themselves did not pass on such patients to surgeons.

But while surgeons failed to take operative endoscopy away from gastroenterologists, they did succeed in asserting similar claims in the case of laproscopy. Here, Zetka argues, interoccupational relationships and timing were the decisive factors. As soon as operative laproscopic techniques were developed in the late 1980s, surgeons seized on them in order to protect themselves against further turf losses by offering less-invasive alternatives to open...