Hundreds of medical school graduates, donning their hard-earned white coats, start their residencies every summer, during which they take on at least a few more years of training in a specialized field, like surgery or pediatrics, before they’re licensed to practise.
Residencies are known to be rigorous learning and work environments, where new doctors move their way up to taking on more responsibility under the guidance and supervision of attending physicians.
Two University of Calgary researchers believe that very program structure can be connected to the man who revolutionized medical training in North America, William Stewart Halsted — and his addiction to cocaine.
Considered the pioneer of modern surgery, the American surgeon is credited with many advances in the field, from perfecting the radical mastectomy surgery for breast cancer to inventing surgical gloves.
Another one of his contributions to medical practice: a novel residency training model he developed at the reputable Johns Hopkins Hospital in Baltimore, Md., during the late 1800s.
The program, characterized by a tiered system in which residents were ranked by seniority and given graded responsibility, may have been designed by Halsted as a way to help him hide his addiction and mask his own deteriorating speed and precision, according to a study in the Canadian Journal of Surgery.
“He brought in all these young students who wanted to be surgeons. He set it up [as a training program], but really they were backing him up,” said Dr. Norman Schachar, a professor emeritus at the University of Calgary’s Cumming School of Medicine, and co-author of the study.
“He started a system where he could weed out the best ones in a pyramidal sort of structure, where the guy who got to be the ‘senior resident’ was the one he hand-picked, who was the most skilled and the smartest. And then he said, ‘You come to the [operating room] with me. Better yet, you go start, and I’ll catch up to you.'”
Co-author and professor emeritus at the University of Calgary’s Cumming School of Medicine James Wright said, “much of the design of the residency program was pretty self-serving in that it basically provided a way for [Halsted] not to have very much contact with patients yet still provide high-quality surgery.”
From experimentation to addiction
Halsted began his career in New York, where he routinely experimented with procedures like the blood transfusion, pushing the boundaries of medical knowledge at the time.
But in 1884, one experiment went too far.
Then-32-year-old Halsted came across a report out of Australia that mentioned a potential new local anesthetic: cocaine.
Experimenting on himself with the drug, Halsted became addicted, and his career as a young surgeon rapidly declined as he went in and out of treatment facilities.
To treat his cocaine addiction, Halsted was given morphine, which he also got addicted to.
Halsted’s addictions would eventually ruin his career in New York, but also lead to the start of his work at John Hopkins, where he would go on to transform the medical field.
After Halsted’s experimentation with cocaine, his surgical style shifted from bold and fast to a “more contemplative, physiologic style, in which conserving tissue and blood was more important than speed” — and achieved better results, the study said.
“I have never seen a wound operated at the top while the bottom was already healed,” William Mayo, the late American surgeon and co-founder of the renowned Mayo Clinic, reportedly commented while watching Halsted perform surgery.
While there is no explicit record of Halsted’s addiction shaping his training model, Schachar said that in reading “between the lines” of the historical record (including Halsted’s published quotes, writing from his former trainees and other surgical scholars, and Gerald Imber’s book Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted) the researchers can conclude that it indeed played a factor.
A new style of medical training
Before Halsted, doctors were trained using an apprenticeship training model, a contrast to his residency program that provided a more structured educational approach based on German training models he admired.
The surgeon’s formal program split training doctors into multiple tiers, a pyramidal structure that involved entry and mid-level positions with one senior role and “intense competition” for advancement, according to Wright.
“The addiction would have left him not [with] perfect surgical skills, but still the intellect to do surgery. And so it just appeared as if this would be … a very good way to kind of hide one’s addiction and at the same time provide outstanding service, because you have this cadre of residents that are all trying to impress the professor,” Wright explained.
Dr. Frank Stahnisch, a historian of medicine and health care at the University of Calgary, said that Schachar and Wright rightly point out “that the residents and assistants had a central and necessary place in the whole Halsted system, namely supporting their master.”
Halsted’s program would go on to produce medical pioneers — like Harvey Williams Cushing, the father of modern neurosurgery – who popularized his training and surgical techniques across North America.
Halsted’s lasting influence on modern-day residency programs
Glen Bandiera, executive director of standards and assessment at the Royal College of Physicians and Surgeons of Canada, said the structure of residency programs has shifted dramatically over the years, from being largely unstructured apprenticeship-type experiences to very structured, time-limited educational programs.
“Every residency program is predicated on this idea of graded responsibility,” he explained, where residents gradually have increased autonomy and accountability over the course of their training.
While that concept, rooted in Halsted’s pyramidal training model, persists in today’s residencies, it is no longer as severe a program as Halsted designed it to be. His model lacked any guarantee that residents would make it to the apex of his pyramid and complete their training.
“It’s fairly well accepted that once you’re in a residency spot, you will continue in that program until you graduate. So the idea that there’s people that may not make it through is relatively rare in Canada,” Bandiera said.
While residency programs have evolved leaps and bounds since Halsted was training emerging doctors at Johns Hopkins, Bandiera said some of his core principles have proven foundational for medical practice.
“The idea that there was a need to provide care to patients 24/7 in the hospital and that the hospitals themselves were both a work environment and a learning environment, and that residents and other learners had to spend a lot of time practising their craft in order to become experts — all of those have proven true.”
