From Barbers to Surgeon-Scientists and Beyond: Creation of the Modern Surgeon

By Connie Shao

This is a special edition blog post presented in partnership with the Society of Asian Academic Surgeons in celebration of Asian American and Pacific Islander Heritage Month.

Surgery did not begin as a science. Early practitioners were barbers, monks, and battlefield medics operating without anesthesia, sterility, or formal training. In ancient Mesopotamia, surgeons drained abscesses and set fractures, blending technical skill with spiritual ritual. As outlined in the Code of Hammurabi written in 1754 BCE, this was all under the threat of severe punishment for failure[1]. By medieval Europe, surgery had been pushed even further from the practice of medicine as we know it today: physicians avoided it, while barber-surgeons, who trained through apprenticeships rather than universities, became the true procedural experts[2,3].

Paradoxically, these “lower-status” surgeons had more practical knowledge than academically trained physicians. That gap began to close during the Renaissance, when figures like Ambroise Paré and Andreas Vesalius challenged dogma with observation, often at great personal and professional risk. These pioneers operated in an environment where innovation meant experimenting on patients without consent, without oversight, and without a systematic way to evaluate outcomes [4,5]. Innovation was often the result of crisis, including military conflict and resource scarcity. John of Arderne encouraged surgeons to trust their own experience over authority, foreshadowing the scientific method centuries before its formalization [6]. Their willingness to trust their own observations over received authority laid the groundwork for evidence-based surgery.

However, innovation came at a cost. For much of history, surgery advanced through trial and error on patients, without consent or systematic evaluation. This unregulated progress produced breakthroughs, as well as harmful practices that spread unchecked [7,8].

In 1889, William Stewart Halsted (1852–1922) established the first formal surgical residency program at Johns Hopkins, transforming surgical training from a disorganized apprenticeship into a structured residency system that integrated clinical practice with laboratory research. His vision was that surgeons should not merely be technicians but should understand the fundamental biology of surgical disease and contribute to scientific advancement.

In the 20^th century, ethical concerns slowly emerged, from early attempts at informed consent to scandals that culminated in modern oversight frameworks like the Belmont Report and institutional review boards [9–11]. Professional organizations such as the American College of Surgeons and the Association for Academic Surgery formalized training, ethics, and research, transforming surgery into a disciplined field grounded in evidence [12–14]. The rise of evidence-based medicine and multicenter trials brought rigor to surgical innovation, replacing anecdote with data. More recently, the IDEAL framework (Idea, Development, Exploration, Assessment, Long-term Study) has provided a structured pathway for evaluating new procedures. Its central principle is simple: “no surgical innovation without evaluation” [15–17]. This model drove major advances across fields spanning from transplantation to quality improvement systems. Linking bedside observations to research questions allowed for a streamlined and regulated process from observation to innovation [18,19].

However, the founders of surgery operated in a world that no longer exists. Their lives were singular in focus: they lived in hospitals, built their identities entirely around their work, and often relied on invisible personal support systems that allowed them to devote nearly every waking hour to surgery. That model, while historically productive, was never broadly accessible, nor was it sustainable or equitable.

Today’s surgical workforce is more diverse, more human, and more complex. Women are no longer peripheral to surgery; they are central to it, now comprising nearly half of surgical trainees and contributing not only to workforce expansion but to measurable improvements in care [20]. Studies show women surgeons demonstrate greater guideline adherence, more patient-centered communication, and, in some analyses, improved outcomes and lower costs [21]. At the same time, cultural expectations have shifted: male surgeons are more engaged in family life and surgeons broadly are no longer willing or able to sustain the total personal sacrifice that defined earlier generations.

Yet, the system has not kept pace. Attrition among women surgeons is not a failure of individual resilience but of institutional design, driven primarily by poor work-life integration (71%) and discrimination (50%), with nearly all reported discrimination being gender-based [22]. Evidence shows that structured support, including paid parental leave, lactation resources, childcare access, and cultures that normalize their use, improve retention and workforce sustainability [23]. Association of Women Surgeons and American College of Surgeons now advocate for comprehensive family support policies, recognizing that sustainable change requires both institutional policies and cultural shifts enabling their use.

Workforce diversity is not just a matter of equity; it is essential to access. International medical graduates (IMGs) now make up approximately 20% of the general surgery workforce and disproportionately serve rural and underserved communities [24]. Visa-sponsored physicians are significantly more likely to practice in high-need areas, making them critical to maintaining access where U.S.-trained surgeons are scarce [25]. H-1B visa-sponsored surgeons are more than twice as prevalent in rural compared to urban counties and more than 4 times as prevalent in the most versus least impoverished counties [24].This is particularly urgent given projected shortages of 15–21% in general surgery and stark geographic disparities, with rural workforce adequacy expected to fall to nearly 40% of need in coming decades [26].

However, the engine of academic surgery that trains future surgeons and drives innovation is under pressure. The expectation of surgeons to perform basic science research alongside their clinical duties was established by the Hunterian Laboratory of Experimental Medicine at Johns Hopkins in 1905 [27]. Now, clinical productivity demands, corporatization, and funding disparities have eroded protected time for research and teaching [28]. Surgeon-scientists represent less than 2% of all NIH investigators despite surgical diseases comprising 28-30% of the global disease burden, with a growing gap in funding compared to PhD investigators [29]. An approximately 40% cut to the 2026 NIH budget has been proposed, with more than $1.5 trillion in cuts outlined through 2034 [30]. 2,291 active research grants were terminated in early 2025, withdrawing $2.45 billion in funding [31]. 694 grants totaling $1.81 billion were terminated between February and April 2025 across 210 institutions [32]. Early-career investigators and women were disproportionately affected by grant terminations: women’s projects were smaller on average, had larger shares of unspent funds, and were more concentrated in training and transition awards [31]. This is not a trivial loss: academic surgeons not only generate innovation but also train the majority of the surgical workforce, amplifying their impact across generations [33].

What role does the academic surgeon play today? Evidence supports team-based science, where surgeons collaborate with PhD investigators and research infrastructure to maintain productivity and relevance [34]. The training multiplier effect is real but does not require research-active faculty. While academic surgeons train the next generation, community-based residency programs also produce competent surgeons who achieve equivalent clinical outcomes [35]. The argument that research-active faculty are essential for training is not supported by outcome data. Equally important is the intentional protection of time – for research, for education, and for life outside the hospital. Without it, the workforce will continue to wither, slowing progress, and costing society significantly as surgeons complete training only to experience attrition afterwards. Across the workforce, almost 3/4 of surgeons report burnout [36], with 26% of surgeons under the age of 60 considering leaving surgery within the next 2 years, citing overall stress (79%), work time demands (77%), and personal time requirements (73%) [37].

Nearly 1 in 3 Americans (approximately 100 million) lack access to quality surgical care, with an estimated annual cost of $1 billion in preventable healthcare spending [38]. Non-metropolitan areas are projected to have only 42.2% workforce adequacy by 2037 compared to 113% in metropolitan areas [39]. Almost 2 in 3 rural general surgeons will be reaching retirement age in the next decade[40]. GME positions have been expanded through the Consolidated Appropriations Acts of 2021, 2023, and 2024, adding 1,200 positions in high-need areas [41]. Proposed legislation would add 2,000 GME positions per year specifically in rural locations and health professional shortage areas, though this has stalled in Congress since 2023. Exposure to rural training can help alleviate geographic maldistribution, with even a 4-week rotation in rural areas almost doubled the probability of working in rural areas [41]. Diversification of the healthcare system is similarly beneficial, with female and underrepresented students more likely to express intent to practice in underserved areas [42].

While surgery was originally forged through centuries of innovation, modern surgery is plagued by the ability to apply the standard of care across the population. The diversification of the field of surgery has allowed for improved outcomes and greater access for our rural patients. However, shortages persist and are expected to worsen. Residency positions must expand across both academic and community training institutions. Institutions must adapt to the administrative burden on surgeons today, institutionalizing protective measures to reduce attrition. Diversification of the workforce is often controversial, though data shows the crucial role it plays in caring for underserved populations. The surgical workforce crisis represents one of the most pressing challenges facing American healthcare. Without coordinated action across training, retention, financial, and policy domains, the gap between surgical need and surgical capacity will continue to widen, with the most vulnerable populations bearing the greatest burden.

Dr. Connie Shao is a Colon and Rectal Surgery fellow at Ochsner Health and incoming faculty at Corewell Health (Michigan State University, Ferguson Clinic) in Grand Rapids, Michigan. Originally from Michigan, she completed general surgery residency at the University of Alabama at Birmingham, where she spent two dedicated research years supported by an American College of Surgeons award and an institutional T32 training grant. Her research is focused on colorectal cancer disparities, rural access to care, and the role of telehealth in perioperative management. She is engaged in national efforts through the American College of Surgeons, including work on defining quality metrics in telehealth. She has also been an active member of the Society of Asian Academic Surgeons since 2021 and highly recommends coming to the annual meeting in September. You can follow her @shao_connie on X.

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