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The making of a neurosurgeon
Dr. William Stewart Halsted, 1922. Photo by John H. Stocksdale.
Courtesy of the National Library of Medicine.
hands-on training, with an experienced surgeon providing
longitudinal mentorship for the young apprentice, and in
many fundamental ways forms the basis for contemporary
surgical residency training.
In the late nineteenth and early twentieth centuries, as
hospitals established themselves as centralized sources of
medical care, the need for a more structured training system
grew. This new system was first proposed by Sir William
Osler at the Johns Hopkins Hospital, 5 although it is William
Stewart Halsted who is most often credited with its inception
at Hopkins in 1889 and its adoption throughout the United
States and Europe soon thereafter. 5,6
Halsted’s residency training bore great similarities to
the apprenticeship model. It was pyramidal, similar to the
training programs in Germany where Halsted had studied. 7
The program had as its hallmark stepped responsibility for
the residents depending on both experience and successful
performance of clinical tasks, 5-7 and weeded out residents
who did not continue to progress during training. This
structure ensured that residents continuing through training
had extensive experience in the operating theater as well as
the wards, but its main drawback was that a percentage of
residents had to leave the program with too much training
to pursue an alternative career and not enough training to be
safe and successful practicing surgeons. 8
The Hopkins program placed strong emphasis on performing
surgery safely, according to the Halstedian method. 6 The
Halstedian principles of aseptic operative technique, careful
handling of delicate tissues, meticulous hemostasis, and approximation
of tissues with minimal tension using multilayered
closures were thoroughly emphasized. 5–7
Under Halsted’s guidance, Cushing learned the fundamentals
for improving surgical outcomes, as well as the importance
of thoughtful, evidence-based medicine. 6,9 In his 1905
address on neurological surgery, Cushing offered his perspective
on both the role of broad surgical training and the need
for further specialization:
granting the wisdom and necessity of a general surgical
training beforehand, I do not see how such particularization
10 The Pharos/Autumn 2012