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Recapturing the History of Surgical Practice Through Simulation-based Re-enactment

  • Roger Kneebone (a1) and Abigail Woods (a2)
Abstract

This paper introduces simulation-based re-enactment (SBR) as a novel method of documenting and studying the recent history of surgical practice. SBR aims to capture ways of surgical working that remain within living memory but have been superseded due to technical advances and changes in working patterns. Inspired by broader efforts in historical re-enactment and the use of simulation within surgical education, SBR seeks to overcome some of the weaknesses associated with text-based, surgeon-centred approaches to the history of surgery. The paper describes how we applied SBR to a previously common operation that is now rarely performed due to the introduction of keyhole surgery: open cholecystectomy or removal of the gall bladder. Key aspects of a 1980s operating theatre were recreated, and retired surgical teams (comprising surgeon, anaesthetist and theatre nurse) invited to re-enact, and educate surgical trainees in this procedure. Video recording, supplemented by pre- and post-re-enactment interviews, enabled the teams’ conduct of this operation to be placed on the historical record. These recordings were then used to derive insights into the social and technical nature of surgical expertise, its distribution throughout the surgical team, and the members’ tacit and frequently sub-conscious ways of working. While acknowledging some of the limitations of SBR, we argue that its utility to historians – as well as surgeons – merits its more extensive application.

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The online version of this article is published within an Open Access environment subject to the conditions of the Creative Commons Attribution licence .
Corresponding author
* Email address for correspondence: r.kneebone@imperial.ac.uk
Footnotes
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We wish to acknowledge the invaluable assistance of numerous clinicians, especially Professor Harold Ellis, Professor Stanley Feldman, Sister Mary Nieland, Mr John Black, Dr Bruce Roscoe and Sister Julia Radley. We also wish to acknowledge Mr Jimmy Kyaw Tun, Mr Sacha Harris, Miss Anne Yeh, Dr Jessica Tang, Dr Jason Maroothynaden and other researchers at Imperial College London. We would like to thank the Wellcome Trust for funding Kneebone’s contribution to this paper via a Wellcome Trust Research Leave Award for Clinicians and Scientists. We acknowledge with gratitude the assistance and support of the Science Museum and its curators (Ms Heather Mayfield, Ms Katie Maggs, Dr Tim Boon, Dr Robert Bud and others) and of Mr Paul Craddock and London Consortium TV for video-recording operations. Max Campbell (Heath Cuts) developed our hybrid cholecystectomy model. Both authors contributed equally to the generation of this paper.

Footnotes
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1. Kneebone trained as a general and trauma surgeon in the 1980s, learning to perform open cholecystectomy in the manner described below. After completing his specialist training he changed direction and became a general practitioner, then moved to academia to develop the field of surgical education. Woods trained as a veterinary surgeon and worked in general practice before retraining as a historian of medicine.

2. These topics feature heavily in overview accounts of the history of surgery. They have also been subjected to dedicated analysis. Key accounts include: A.J. Harding Rains, Joseph Lister and Antisepsis (Hove: Priory Press, 1977); M. Pernick, A Calculus of Suffering: Pain, Professionalism and Anaesthesia in Nineteenth-Century America (New York: Columbia University Press, 1985); Lindsay Granshaw, ‘Upon this principle I have based a practice’: The development and reception of antisepsis in Britain, 1867–90’, in J. Pickstone (ed.), Medical Innovations in Historical Perspective (London: Macmillan, 1992), 17–46; Roger Cooter, Surgery and Society in Peace and War: Orthopaedics and the Organization of Modern Medicine, 1880–1948 (Basingstoke: Macmillan, 1993); Emily Mayhew, The Reconstruction of Warriors: Archibald McIndoe, the Royal Air Force, and the Guinea Pig Club (London: Greenhill Books, 2004); Stephanie Snow, Operations without Pain: The Practice and Science of Anaesthesia in Victorian Britain (Basingstoke: Palgrave MacMillan, 2006); Peter Jones, A Surgical Revolution: Surgery in Scotland 1837–1901 (Edinburgh: John Donald, 2007).

3. Andrew Warwick, ‘X-rays as evidence in German orthopaedic surgery, 1895–1900’, ISIS, 96 (2005), 1–24.

4. For example: Harold Ellis, A History of Surgery (London: Greenwich Medical Media Ltd, 2001); Knut Haeger, The Illustrated History of Surgery (London: Harold Starke Publishers, 1988); Nicholas Tilney, Invasion of the Body: Revolutions in Surgery (London: Harvard University Press, 2011); J. Kirkup, The Evolution of Surgical Instruments: An Illustrated History from Ancient Times to the 20th Century (Novato, California: Norman Publishing, 2006). For a critique of this literature, see Christopher Lawrence, ‘Democratic, divine and heroic: The history and historiography of surgery’ in: C. Lawrence (ed.) Medical Theory, Surgical Practice: Studies in the History of Surgery (London: Routledge, 1992), 1–47.

5. For an early sociological analysis of surgical teamwork, see R.N. Wilson, ‘Teamwork in the operating room’, Human Organisation, 12 (1954), 9–14. Its contemporary dimensions are discussed by: S. Timmons and J. Tanner, ‘A disputed occupational boundary: Operating theatre nurses and operating department practitioners’, Sociology of Health and Illness, 26 (2004), 645–66; R. Finn, ‘The language of teamwork: Reproducing professional divisions in the operating theatre’, Human Relations, 61 (2008), 103–30.

6. Charles Webster, The National Health Service: A Political History, 2nd edn (Oxford: Oxford University Press, 2002); G. Rivett, National Health Service History (http://www.nhshistory.net/, 2008); R. Canter, ‘Impact of reduced working time on surgical training in the United Kingdom and Ireland’, Surgeon, 9, Suppl. 1 (2011), S6-7.

7. S. Wilde and G. Hirst, ‘Learning from mistakes: Early twentieth-century surgical practice’, Journal of the History of Medicine and Allied Sciences, 64 (2008), 38–77, uses the diaries of Australian surgeon, Archibald Watson, to describe the culture of ‘learning by doing’ within surgical practice. Other aspects of surgeons’ expertise and their decision making processes are examined in S. Wilde, ‘See one, do one, modify one: Prostate surgery in the 1930s’, Medical History, 48 (2004), 351–66. Also see Sally Wilde, The History of Surgery: Trust, Patient Autonomy, Medical Dominance and Australian Surgery, 1890–1940, available at http://www.thehistoryofsurgery.com/wp-content/uploads/2010/07/book.pdf. Thomas Schlich, Surgery, Science and Industry: A Revolution in Fracture Care, 1950s–90s (Basingstoke: Palgrave Macmillan, 2002) describes the creation and dissemination of a uniform method of fracture repair by Swiss surgeons in the later 20th century. Julie Anderson, Francis Neary and John Pickstone, Surgeons, Manufacturers and Patients: A Transatlantic History of Total Hip Replacement (Basingstoke: Palgrave Macmillan, 2007) situates the development and use of hip replacement techniques within the context of health care costs and priorities, industrial development and patient perspectives.

8. Bruno Latour and Steve Woolgar, Laboratory Life: The Social Construction of Scientific Facts (London: Sage, 1979); D Baird, Thing Knowledge: A Philosophy of Scientific Instruments (London: University of California Press, 2004); Harry Collins and Robert Evans, Rethinking Expertise (Bristol: University of Chicago Press, 2007); Harry Collins, Tacit and Explicit Knowledge (London: University of Chicago Press, 2010).

9. S. Hirschauer, ‘The manufacture of bodies in surgery’, Social Studies of Science, 21 (1991), 279–319; H. Collins, ‘Dissecting surgery: Forms of life depersonalized’, Social Studies of Science, 24 (1994), 311–33. See also the responses to Collins by N. Fox, ‘Fabricating Surgery’, M. Lynch, ‘Collins, Hirschauer and Winch: Ethnography, Exoticism, Surgery, Antisepsis and Dehorsification’ and S. Hirschauer, ‘Towards a methodology of investigations into the strangeness of one’s own culture’, Social Studies of Science, 24 (1994), 335–89.

10. Ibid.; P. Katz, The Scalpel’s Edge: The Culture of Surgeons (London: Allyn and Bacon, 1999); T. Moreira, ‘Coordination and embodiment in the operating room’, Body and Society, 10 (2004), 109–29; J. Bezemer, A. Cope, G. Kress and R. Kneebone, “‘Can I have a Johann, please?”: Changing social and cultural contexts for professional communication’, Applied Linguistics Review, 2 (2011), 313–34; J. Bezemer, G. Murtagh, A. Cope, G. Kress and R. Kneebone, “‘Scissors, please”: The practical accomplishment of surgical work in the operating heater’, Symbolic Interaction, 34 (2011), 398–414.

11. J. Lave and W.E. Wenger, Situated Learning: Legitimate Peripheral Participation (Cambridge: Cambridge University Press, 1991); T. Moreira, ‘Coordination and embodiment’, ibid.; P. Lyon, ‘A model of teaching and learning in the operating theatre’, Medical Education, 38 (2004), 1278–87; J. Bezemer, G. Kress, A. Cope and R. Kneebone, ‘Learning in the operating theatre: A social semiotic perspective’, in V. Cook, C. Daly & M. Newman (eds). Work-Based Learning in Clinical Settings: Insights from Socio-cultural Perspectives (Abingdon: Radcliffe, 2012), 125–41; R. Prentice, Bodies in Formation: An Ethnography of Anatomy and Surgical Education (Durham: Duke University Press, 2013); J. Bezemer, ‘Gesture in operations’, in C. Jewitt (ed.), Handbook of Multimodal Analysis, 2nd edn, (London: Routledge, 2013).

12. C. Bosk, Forgive and Remember: Managing Medical Failure, 2nd edn (Chicago: University of Chicago Press, 2003).

13. H. Collins, ‘Expert-systems and the science of knowledge’, in W. Bijker, T. Hughes and T. Pinch (eds), The Social Construction of Technological Systems (Cambridge, MA: MIT Press, 1987), 329–48; A. Cambrosio and P. Keating, Exquisite Specificity: The Monoclonal Antibody Revolution (Oxford: Oxford University Press, 1995), 45–79; Schlich, op. cit. (note 7).

14. Kate Fisher, ‘Oral testimony and the history of medicine’ in M. Jackson (ed.) The Oxford Handbook of the History of Science (Oxford: Oxford University Press, 2011), 598–616.

15. Hirschauer,‘The manufacture of bodies’ (note 9).

16. For example: Rodney Maingot, Abdominal Operations (New York: Appleton-Century-Crofts, 1980); Cholecystectomy (1983, Training video, Royal College of Surgeons of England).

17. G. Lawrence, ‘The ambiguous artefact: Surgical instruments and the surgical past’ in: C. Lawrence (ed.) Medical Theory, Surgical Practice: Studies in the History of Surgery (London: Routledge, 1992), 301.

18. For example, C. Timmermann and J. Anderson (eds), Devices and Designs: Medical Technologies in Surgical Perspective (Basingstoke: Palgrave Macmillan, 2006).

19. G. Dening, Mr Bligh’s Bad Language: Passion, Power, and Theatre on the Bounty (Cambridge: Cambridge University Press, 1992); W.H. Dray, History as Re-enactment: R.G. Collingwood’s Idea of History (Oxford: Clarendon Press, 1995); R. Rosenzweig and D. Thelen, The Presence of the Past: Popular Uses of History in American Life (New York: Columbia University Press, 1998); J. Thompson, War Games: Inside the World of Twentieth-Century War Re-enactors (Washington: Smithsonian Books, 2004); D. Agnew, ‘History’s affective turn: Historical re-enactment and its work in the present’, Rethinking History, 11, 3 (2007), 299–312.

20. Alexander Cook, ‘The use and abuse of historical re-enactment: Thoughts on recent trends in public history’, Criticism, 46, 3 (2004), 487–96.

21. Ibid., 491.

22. Lawrence Principe, ‘Alchemy restored’, ISIS, 102 (2011), 305–12; Lawrence Principe, Secrets of Alchemy (London: University of Chicago Press, 2012).

23. Heering, Peter, ‘On Coulomb’s inverse square law’, American Journal of Physics, 60 (1992), 988994.

24. Belloni, L., ‘The repetition of experiments and observations: Its value in studying history of medicine (and science)’, Journal of the History of Medicine and Allied Sciences, 25 (1970), 158167.

25. Sibum, Otto, ‘Reworking the mechanical value of heat: instruments of precision and gestures of accuracy in early Victorian England’, Studies in History and Philosophy of Science, 26 (1995), 73106.

26. Chang, Hasok, Is Water ? Evidence, Realism and Pluralism (Dordrecht: Springer, 2012). See also http://www.hps.cam.ac.uk/people/chang/boiling/index.htm.

27. P. Heering, ‘Getting shocks: Teaching secondary school physics through history’, Science & Education, 9(4) (2000), 363–73; Hasok Chang, ‘How historical experiments can improve scientific knowledge and science education: The cases of boiling water and electrochemistry’, Science Education 20 (2011), 317–41; Dietmar Hottecke, Andreas Henke and Falk Riess, ‘Implementing history and philosophy in science teaching: Strategies, methods, results and experiences from the European HIPST Project’, Science Education, 21 (2012), 1233–61.

28. R. Kneebone and F. Bello, ‘Surgical simulation’, in R. Riley (ed.), Manual of Simulation in Healthcare, (Oxford: Oxford University Press, 2008), 435–48; R. Kneebone and R. Aggarwal, ‘Surgical training using simulation’, BMJ, 338 (2009), b1001; V.N. Palter and T.P. Grantcharov, ‘Simulation in surgical education’, Canadian Medical Association Journal, 182 (2010), 1191–6.

29. P. Dieckmann, D. Gaba and M. Rall, ‘Deepening the theoretical foundations of patient simulation as social practice’, Simulation in Healthcare, 2 (2007), 183–93; D.M. Gaba, ‘The future vision of simulation in health care’, Quality and Safety in Health Care, 13, Suppl. 1 (2004), 2–10.

30. Bezemer et al., op. cit. (note 11) , 125–41; Kneebone and Bello, op. cit. (note 28), 435–48; R. Kneebone, ‘Simulation, safety and surgery’, Quality & Safety in Health Care, 19, Ergonomics & Safety Supplement (2010), i47-52; E. Kassab, J.K. Tun and R. Kneebone, ‘A novel approach to contextualized surgical simulation training’, Simulation in Healthcare, 7 (2012), 155–61.

31. Kneebone, ibid., i47–52; E. Kassab, J.K. Tun, S. Arora, D. King, K. Ahmed, D. Miskovic, A. Cope, B. Vadhwana, F. Bello, N. Sevdalis and R. Kneebone, “‘Blowing up the barriers” in surgical training: Exploring and validating the concept of distributed simulation’, Annals of Surgery, 254 (2011), 1059–65.

32. J.J. Tang, J. Maroothynaden, F. Bello, R.L. Kneebone. ‘Public engagement through shared immersion: Participating in the processes of research’. Science Communication, 2012, 26 November 1075547012466389.

33. Rodney Maingot, Abdominal Operations (New York: Appleton-Century-Crofts, 1980).

34. Cholecystectomy (1983, Training video, Royal College of Surgeons of England).

35. M. Farquharson, B. Moran (eds), Farquharson’s Textbook of Operative General Surgery (Hodder Arnold Publication, 2005).

36. Canter, op. cit. (note 6), s6–7; J. Temple, ‘Time for training: A review of the impact of the European Working Time Directive on the quality of training’ (http://www.mee.nhs.uk/PDF/14274%20Bookmark%20Web%20Version.pdf, 2010); C. Morris, ‘Reimagining “the firm”: Clinical attachments as time spent in communities of practice’, in V. Cook, C. Daly and M. Newman (eds), Work-Based Learning in Clinical Settings (Milton Keynes: Radcliffe Publishing, London, 2012), 11–26.

37. Dixon-Woods, M., Yeung, K. and Bosk, C., ‘Why is UK medicine no longer a self-regulating profession? The role of scandals involving “Bad Apple” doctors’, Social Science & Medicine, 73 (2011), 14521459.

38. Bracegirdle, B., The Wellcome Museum of the History of Medicine: A Part of the Science Museum (London: Science Museum, 1981).

39. From within Imperial College we were able to garner a full set of cholecystectomy instruments together with an anaesthetic machine (Boyle’s machine with Manley ventilator) from the period. Advice and information was provided by curators of and specialist advisers to the Hunterian Museum (Royal College of Surgeons of England), Association of Anaesthetists, Wellcome Collection, Thackray Museum and the Army Medical Museum. Additional material (including scrubs, gowns and caps) were hired from Film & TV Medical, which provides an extensive resource of authentic equipment and consumables for drama and documentary production.

40. Bezemer, Cope and Kneebone op. cit. (note 11), 125–41; Bezemer, Cope, Kress and Kneebone, op. cit. (note 10), 398–414; J. Hindmarsh and A. Pilnick, ‘The tacit order of teamwork: Collaboration and embodied conduct in anaesthesia’, The Sociological Quarterly, 43(2) (2002), 139–64; D. Goodwin, Acting in Anaesthesia: Ethnographic Encounters with Patients, Practitioners and Medical Technologies (Cambridge: Cambridge University Press, 2009).

41. Kneebone, R. and Woods, A., ‘Bringing surgical history to life’, BMJ, 345 (2012), e8135.

42. Dunham, R. and Sackier, J., ‘Is there a dilemma in adequately training surgeons in both open and laparoscopic biliary surgery?’, Surgical Clinics of North America, 74 (1994), 913921.

43. Pitt, R., ‘Commentary: Is there a dilemma in adequately training surgeons in both open and laparoscopic biliary surgery?’, Surgical Clinics of North America, 74 (1994), 928.

We wish to acknowledge the invaluable assistance of numerous clinicians, especially Professor Harold Ellis, Professor Stanley Feldman, Sister Mary Nieland, Mr John Black, Dr Bruce Roscoe and Sister Julia Radley. We also wish to acknowledge Mr Jimmy Kyaw Tun, Mr Sacha Harris, Miss Anne Yeh, Dr Jessica Tang, Dr Jason Maroothynaden and other researchers at Imperial College London. We would like to thank the Wellcome Trust for funding Kneebone’s contribution to this paper via a Wellcome Trust Research Leave Award for Clinicians and Scientists. We acknowledge with gratitude the assistance and support of the Science Museum and its curators (Ms Heather Mayfield, Ms Katie Maggs, Dr Tim Boon, Dr Robert Bud and others) and of Mr Paul Craddock and London Consortium TV for video-recording operations. Max Campbell (Heath Cuts) developed our hybrid cholecystectomy model. Both authors contributed equally to the generation of this paper.

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Keywords

Type Description Title
VIDEO
Supplementary materials

Kneebone Supplementary Movie
Movie 3. Mr John Black's team operating.

 Video (42.7 MB)
42.7 MB
VIDEO
Supplementary materials

Kneebone Supplementary Movie
Movie 1. Professor Stanley Feldman demonstrating an anaesthetic machine.

 Video (49.3 MB)
49.3 MB
VIDEO
Supplementary materials

Kneebone Supplementary Movie
Movie 2. Professor Harold Ellis’s team operating.

 Video (135.0 MB)
135.0 MB

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