The Ancient Physician Galen, Modern Surgical Training, and the Steri-strip Debate

| May 15, 2014

by Katherine van Schaik, MA, MD PhD Candidate

Katherine van Schaik, MA, MD PhD Candidate, is from Harvard Medical School and the Harvard Department of the Classics in Boston, Massachusetts.

Bariatric Times. 2014;11(5):14–15.

It is no wonder that, while others wandered around the whole city performing salutations and dined with the rich and powerful and escorted them about, and we on the other hand labored diligently the entire time, we first learned all the things that were creditably discovered by the ancients; then through deeds we both tested and practiced them.
Galen, Method of Medicine 9.4, 10.609K

“Do you have a preference for placing the Steri-strips?” I asked. “Some people overlap them, and others don’t.”

The bariatric surgery fellow did not look up from the sterile field but continued to inspect sutures and replied, “It doesn’t matter. On little things like that, it never does. You’re going to hear so many different things during your training. When you operate with someone, you do it their way; when you’re an attending, you do it your way.”

I was a third-year medical student (the year in which medical students undertake full-time clinical training in the hospital) on Week 5 of my 12-week surgery rotation. For the first four weeks, I had mostly observed transplant operations and two-attending cases, which left little opportunity for a medical student to participate in even simple tasks. While completing my extended four-week bariatric rotation, during which I found myself discussing Steri-strip application with the bariatric fellow, I was granted opportunities to be involved more extensively. I began by holding the camera and by sewing closed the one-inch or smaller incisions produced by the laparoscopy ports, through which surgeons place the cameras and instruments of minimally invasive surgery.

For readers unfamiliar with Steri-strips, the process of wound closure involves cleaning and dressing the sewn incision, which is done with the small, tape-like Steri-strips, placed perpendicularly to the line of the incision. Some attendings wanted these dressing strips overlapped; others vociferously did not, which is why I asked the fellow about this particular attending surgeon’s preference.

The response I received from the fellow made intuitive sense: an attending surgeon is “the attending of record,” and the patient is his or her responsibility. Fellows, residents, interns, and medical students assist and learn from the attending surgeon, whose experience ensures the success of the surgery and the safety of the patient. Had medical training always worked this way?

I’m a medical student, and I’m also a student of history, completing PhD studies in ancient history, the history of medicine, and paleopathology under the auspices of the Harvard Department of the Classics. Study of Latin and classical Greek, of historiography and of archaeology, of anthropology and of art history, and of the evolution of medical doctrine and education informs how I understand my own medical education. What one generation of physicians and surgeons values, and how that generation chooses to impart its experience and wisdom to the next, changes with time. Would the physicians and surgeons of the ancient Greco-Roman world, I wondered, have shared this bariatric fellow’s sentiment regarding training?

Medical training in the United States today is highly regulated. Students take qualification exams and complete set courses in order to be accepted into medical school. They also fulfill requirements imposed upon their medical schools by the Liaison Committee on Medical Education; residency programs have their own respective requirements for hours of work completed, exams passed, procedures done, and clinics held. But medical training wasn’t always this way.

The quote with which I began is from a work attributed to the physician Galen (129–c200/c216 CE), a Roman citizen of Greek heritage who was a physician, surgeon, philosopher, and medical educator. His works, and works attributed to him, constitute nearly 10 percent of the entire extant corpus of ancient Greek literature. Galen, one author, is identified (whether correctly or incorrectly) as the originator of 10 percent of such literature. In other words, Galen’s texts about health—how to achieve and to maintain it—were of such value that individuals sought to have these texts laboriously copied and recopied by hand, leading to their preservation through the medieval period and up to the present time.

Did Galen complete a residency or fellowship? The short and overly simple answer to this question is, “No.” Medical training in the ancient world was not regulated as it is today. The people of Greco-Roman antiquity were unsure even how to classify a physician. “Was he an intellectual, a craftsman, a philosopher, rhetorician, or all of the above? The physician’s role in ancient society was complex and his education was not limited to anatomy.”[1] The great Galen, for example, followed a diverse and likely atypical program of study (if we may call it such). Beginning at age 16, he studied with physicians subscribing to different schools of medical thought and practice in the city of Pergamum in modern Turkey. At least two of these teachers were of the Empiricist school, meaning that they subscribed to the belief of the importance of experience in medical education. For example, experience could be gained through direct observation of which drugs worked to address a particular set of symptoms and which did not, and by observation of anatomical dissections and study of bones. Students could also gain knowledge through learning from the experience of other physicians and surgeons, transmitted orally or in writing. This involved studying Hippocratic texts, which were already half a millennium old by the time Galen was practicing.[2]

Galen traveled around the Mediterranean in search of medical knowledge, passing through Smyrna, to Corinth, and then to Alexandria, considered in its time the most prestigious center of learning in the ancient world. Here, Galen learned through the study of human bones and animal dissections. During his training and years of practice, Galen especially desired to learn from students of a physician named Quintus, “renowned as an anatomist and as continuator of the tradition of his own teacher, Marinus, whose comprehensive work on anatomy was the equivalent of the standard graduate-level textbook on the subject at the time.”[3] Throughout his training, Galen interacted directly with patients and valued direct, repeated experience, stating[4]:

“The best teaching is the teaching by live voice, and….from a book neither the helmsman nor the practitioner of any craft can be trained. These [books] are memoranda for those who are already learned, not a complete education for the ignorant.”
(Aliment. Fac. 1.1, 6480K)

“The learning of methods only, without a variety of practices in them, is unable to produce well-trained students.”
(Loc. Affect. 2.10, 8.123K)

Of those who have seen the parts of the body shown by a teacher, none is able to remember accurately having seen them only once or twice, but it is necessary to see them many times.
(Comp. Med. Gen. 3.2, 13.608K)

Galen’s medical studies were largely self-directed, though he sought out individuals whom he believed could provide direction. He was atypical for his own time, and he was atypical in his metaphorical afterlife in the extent to which his work was regarded as authoritative in both the western Judeo-Christian and eastern Islamic traditions until the 16th century. We cannot be sure of the extent to which his own experiences and training are generalizable to the physicians of Greco-Roman antiquity who came before or after him. We may observe in his writings, though, an emphasis upon the praxis that is so highly valued in modern medical education: learning by doing, by seeing patients, and by seeing more patients. Galen acknowledges debts to predecessors, such as Hippocrates and Quintus, aware that one’s choice of medical texts and the school of practice to which one subscribes influences daily practice, trainees, and patients. Galen was not shy about disagreeing with other physicians and records multiple instances in which he humiliated physicians whose practices he found incorrect and ineffective, or in which he saved patients from their ignorance or foolishness in subscribing to other schools of medical thought.[5]

While Galen did not take an exam to earn the privilege of studying with his teachers, or fulfill residency program requirements imposed by an external board in order to receive a license to practice medicine, the fundamentals of his training remain cornerstones of medical and surgical education today. Students, residents, and fellows know that the best way to learn is by doing, by seeing patients early and often. They know that they must “labor diligently and often”. They know that they must seek out mentors who will instruct and inspire them, as fellows do when they seek to work under the supervision of specific surgeons. Modern students of medicine know that they, like Galen, will on occasion, by testing and practicing, disagree with other practitioners. This is precisely why we no longer practice Galenic medicine.[5]

Galen did not use Steri-strips, but he most certainly would have voiced his opinion about whether they should overlap.

References
1. Wilson N. Review of M. Horstmanshoff (ed.), Hippocrates and Medical Education. Bryn Mawr Classical Review 2011.07.28.
2. Mattern S. The Prince of Medicine: Galen in the Roman Empire. Oxford; New York: Oxford University Press, 2013.
3. Ibid., 75.
4. Ibid., 63.
5. Mattern S. Galen and the Rhetoric of Healing. Baltimore, Johns Hopkins University Press: 2008.

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