Assessing risk to improve outcomes is not a new principle. Formal assessment of patient care to improve outcomes dates back millennia. While it may be hard to establish an exact beginning, there are historical times and iconoclastic health-care providers who stand out as important contributors to the modern concepts of quality assessment and performance improvement. At least six individuals stand out as iconoclasts in the field of performance improvement in surgery (Table 7-1). From the practice-changing observational studies of medieval surgeons like Albucasis and Trotula to the twentieth century insistence on evidence-based studies and randomized controlled trials (RCTs) by Archie Cochrane, many individuals served as champions of performance improvement using the tools of their times. The six people outlined in Table 7-1 had exceptional effects on differentiating good from bad outcomes and on implementing process improvements that benefit our patients today. Each of these six shared a common life experience. At some time in their careers, they were outcasts among their peers. Their peers, and in some cases the public, chastised them for stating the obvious. Thankfully, they persisted despite these unpopular reactions. Reading the historical accounts of these six individuals reminds one that today’s public resistance to straight-forward observations is a long-standing perpetual obstacle that surgical leaders overcame.
Table 7-1:Shaping the Quality of Surgical Care Over Millennia |Favorite Table|Download (.pdf) Table 7-1: Shaping the Quality of Surgical Care Over Millennia
|Health-care Provider (Surgeon, Midwife, or Nurse) ||Time Period ||Contributions |
|Albucasis of Andalusia ||Around 900 A.D. || |
Most frequently cited surgical author of the middle ages.121
Greatest contribution to medicine is the Kitab al-Tasrif, a thirty-volume encyclopedia of medical practices.
Instrumental in transforming medicine from “philosophy” to an actual discipline. Met with great resistance from peers who favored less invasive interventions.
May be the “father of modern surgery” because of his insistence on observational studies, proper training, and use of operative techniques.
Firsts include—description of ectopic pregnancy; hereditary nature of hemophilia; performance of bowel surgery; use of surgical instruments for procedures including breast surgery, urethral exam, tooth implant, stone removal (kidney, bladder, and gall bladder), important advances in pharmacology (prepared medicines by sublimation and distillation).
|Trota of Salerno ||Around 1200 A.D. || |
Advised women on conception, menstruation, pregnancy, caesarian sections, and childbirth as a female faculty member of the Medical School of Salerno.
Wrote a textbook that impacted practice for 300-400 years.122
Her radical ideas on conception shocked the medical and social community. Based on observational studies, Trotula believed that not only women, but men, both have physiologic and anatomic defects that cause conception difficulties.
Defined the concept of “laudable pus” for wound abscess drainage.
|Angelique du Coudrey of France ||Mid 1700s |
As a practicing midwife, Mme du Coudray violated the majority of standards demanded of midwives; she had no children of her own, was not married, and believed in the organization and ...