The Evolution and History of the Royal Colleges of Surgeons

The Royal Colleges of Surgeons are independent professional organizations dedicated to promoting and advancing standards of surgical care for patients, regulating surgery and dentistry, and overseeing the training and assessment of surgeons. These colleges play a crucial role in maintaining surgical standards and ensuring the competence of surgeons. While independent, they share core functions related to teaching, training, assessment, and the maintenance of surgical standards.

Origins and Development of Royal Colleges

The term "Royal College of Surgeons" is a generic term applied to any of six professional organizations worldwide. The Colleges are located in and named for England, Edinburgh, Glasgow, Australasia and Canada. Four of the Royal Colleges, those of England, Edinburgh, Ireland and Australasia are concerned primarily with surgical and dental surgical matters, while those in Canada and Glasgow deal also with the education and assessment of physicians. Surgery has a rich history, and in order to understand the various training pathways for aspiring surgeons one must have an appreciation of the evolution of surgery. Some of the earliest evidence of dedicated surgical procedures were discovered by Paul Broca, where during his anthropological work he concluded that trepanation of the skull had been performed as far back as 7000 years ago.

Royal College of Surgeons of Edinburgh

The Royal College of Surgeons of Edinburgh originated as the medieval craft Guild of Surgeons and Barbers, which became the Incorporation of Surgeons and Barbers in 1505 with the award of a charter. This charter received Royal approval from King James IV the following year. The barbers left the Incorporation in 1722.

Royal College of Surgeons in Ireland

The Royal College of Surgeons in Ireland is the lineal descendant of the 1784 Dublin Society of Surgeons. The earlier Guild of Barbers of Dublin, had received a Royal Charter from King Henry VI in 1446 and a further charter in 1687 expanded the guild to include apothecaries and periwig-makers, so that the voting power of the surgeons in the guild was greatly diminished. In 1784 a group of Dublin surgeons, frustrated with this arrangement, broke away from the guild to form the Dublin Society of Surgeons. This society petitioned King George III for a Royal charter.

Royal College of Surgeons of England

The Royal College of Surgeons of England arose from the Guild of Surgeons which was established in 1435. Certain sources date this as occurring in 1368. There was an ongoing dispute between the surgeons and barber surgeons until an agreement was signed between them in 1493, giving the fellowship of surgeons the power of incorporation. This union was formalised further in 1540 by Henry VIII between the Worshipful Company of Barbers (incorporated 1462) and the Guild of Surgeons to form the Company of Barbers and Surgeons of London. In 1745 the surgeons broke away from the barbers to form the Company of Surgeons. In 1800 the Company was granted a Royal Charter to become the Royal College of Surgeons in London.

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The Royal College of Surgeons of England (RCS England) is an independent professional body and registered charity that promotes and advances standards of surgical care for patients, and regulates surgery and dentistry in England and Wales. The college is located at Lincoln's Inn Fields in London.

Royal Australasian College of Surgeons

The Royal Australasian College of Surgeons had its origins in 1925 when a group of Australasian surgeons visited the meeting of the American College of Surgeons to observe the structure and functions of a surgical college. When the Australasian Medical Congress met two years later, those surgeons presented detailed proposals for the formation of a surgical college and this was agreed. The College evolved during the years 1925 to 1927. The first official meeting of the College Council was held in February 1927. The official history of the College, The Mantle of Surgery, was written in 2002 by Arthur Wyn Beasley, a RACS Fellow. The first female Fellow was Lillian Violet Cooper, from Queensland, who was admitted to Fellowship on 17 June 1927. The first female surgeon to become a Fellow by passing the RACS Fellowship Examination was Lorna Sisely (1916-2004) from Victoria, who was admitted to Fellowship in June 1947.

Royal College of Physicians and Surgeons of Glasgow

The Royal College of Physicians and Surgeons of Glasgow was established in 1599 by a charter from King James VI. It was termed a faculty, but had the same functions as a medical Royal College. The institution was given Royal status in 1909 when it became the Royal Faculty of Physicians and Surgeons of Glasgow.

The Royal College of Surgeons of England: A Closer Look

Historical Development

The Company of Surgeons moved from Surgeon's Hall in Old Bailey to a site at 41 Lincoln's Inn Fields in 1797. The British government presented the collection of John Hunter to the surgeons after acquiring it in 1799, and in 1803 the company purchased the adjoining house at 42 Lincoln's Inn Fields to house the collection, which forms the basis of The Hunterian Museum. Construction of the first College building, to a design by George Dance the Younger, and James Lewis, took place on this site from 1805 to 1813. The company soon outgrew these premises and in 1834 No. 40, Lincoln's Inn Fields was acquired and demolished along with the George Dance building, of which only a portion of the portico was retained. Sir Charles Barry won the public competition to design a replacement, constructing a facade largely of artificial stone composed of cast blocks of concrete and stucco. Planning consent for a major rebuilding of the non-listed buildings of the Royal College of Surgeons was granted by Westminster City Council in January 2017. The redevelopment of building has been designed by the architecture practice Hawkins\Brown. Barry's famous north frontage and library have been preserved and restored and The Hunterian Museum has benefited from a new façade and entrance on Portugal Street, to the south of the site.

The Hunterian Museum

In 1799 the government purchased the collection of John Hunter which they presented to the college. This formed the basis of the Hunterian Collection, which has since been supplemented by others including an Odontological Collection (curated by A. E. W.

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Distinctions and Titles

The correct way to address a member or fellow of the Royal College of Surgeons is to use the title Mr, Miss, Mrs, Ms, or Mx (not Dr). This system (which applies only to surgeons, not physicians) has its origins in the 16th century, when surgeons were barber-surgeons and did not have a medical degree (or indeed any formal qualification), unlike physicians, who, by the 18th century, held a university medical degree and could thus be referred to as "Doctor". By the time the College of Surgeons received its royal charter in 1800, the Royal College of Physicians were insisting that candidates for membership of the College of Surgeons must first have a medical degree. Therefore, the ensuing years saw aspiring surgeons having to study medicine first and hence receive the title 'doctor'. Thereafter, having obtained the diploma of Member or Fellow of the Royal College of Surgeons he would revert to the title "Mr" as a snub to the RCP.

Awards and Lectures

The college bestows several awards and holds prestigious lectures, including:

The Cheselden Medal: Instituted in 2009 in honour of William Cheselden "to recognise unique achievements in, and exceptional contributions to, the advancement of surgery".
The Royal Colleges' Bronze Medal: Instituted in 1957 and is awarded jointly with the Royal College of Physicians and the Royal College of Obstetricians and Gynaecologists.
The Wood Jones Medal: Instituted in 1975 to commemorate Frederic Wood Jones (Sir William Collins Professor of Human and Comparative Anatomy and Conservator of the Anatomy Museum 1945-52).
The Clement-Price Award: Founded in 1958 with a gift of 1,000 guineas from members of the staff of the Westminster Hospital in honour of Sir Clement Price Thomas.
The Lister Medal: Has been awarded since 1924 (mostly on a triennial basis), after the college was entrusted in 1920 with administrating the Lister Memorial Fund, in memory of pioneering British surgeon Joseph Lister. The award is decided in conjunction with the Royal Society, the Royal College of Surgeons in Ireland, the University of Edinburgh, and the University of Glasgow.
The Honorary Gold Medal: Instituted in 1802 and is awarded at irregular intervals "for liberal acts or distinguished labours, researches and discoveries eminently conducive to the improvement of natural knowledge and of the healing art".
The Bradshaw Lecture: Was founded in 1875 under the will of Mrs Sally Hall Bradshaw in memory of her husband, Dr William Wood Bradshaw. It is a biennial (annual until 1993) lecture on surgery, customarily given by a senior member of the council on or about the day preceding the second Thursday of December.
The Hunterian Oration: Was founded in 1853 when a bequest was made by the executors of John Hunter's will, to provide for an annual dinner and oration in memory of the famous surgeon.

Surgical Training and Education

The surgical royal colleges have a statutory function to oversee the training of surgeons and their assessment by examination. In recent years there has been considerable emphasis on the education of surgeons. The 4 royal colleges are linked with the various specialty surgical associations through the Senate of Surgery, a surgical forum that has an advisory rather than an executive role. Entry into the European Economic Community resulted in the UK adopting the definition of a specialist as defined in Europe. Training comprises 2 years of basic surgical training (BST) followed by 6 years of higher surgical training (HST). During this time, 2 examinations are taken: the MRCS (Membership of the Royal College of Surgeons) at the completion of BST and the specialty FRCS (Fellowship of the Royal College of Surgeons) toward the end of HST. A certificate of completion of specialist training is awarded, and the specialist, now aged 34 to 38 years, is eligible to apply in open competition for a UK (NHS) consultant post or to move to another European Union member state. This 8-year training period is considerably shorter than in the past, when training relied on an apprenticeship system of 12 to 14 years. Most candidates for a consultant post must have not only completion of training in their speciality but also additional experience in their areas of special interest.

To enter a BST program, the beginning surgeon must complete an intern year or possess a recognized qualification obtained in the European Union or elsewhere. Basic surgical training requires 2 years in educational posts approved by the royal colleges, with 12 months spent in 2 different specialties, each with a significant component of surgical emergencies requiring general patient care and care of the critically ill, eg, general surgery, orthopedics, or accident and emergency. The remaining 12 months is spent in other specialties, either two 6-month posts or three 4-month posts. In all, the trainee must experience 3 separate surgical specialties with no more than 6 months in any one specialty. There is a mandatory basic surgical skills course and a voluntary advanced trauma life support course and a care of the critically ill surgical patient course. The trainee keeps a log in which operations are recorded, with a note as to whether the trainee was an assistant, performed the surgery under supervision, or performed the surgery independently. This log also records complications. Training is controlled by the training boards of the royal colleges, which devolve responsibility to surgical tutors and regional advisors, who in turn liaise with the postgraduate deans.

In 1994, the Royal College of Surgeons of England launched the first distance learning course for the FRCS Part II (Clinical Surgery in General), known as the Surgeons in Training Education Programme (STEP). This has now been adapted for the new MRCS diploma. The MRCS syllabus differs from the old-style FRCS syllabus because the period of training is 2 years compared with 4 years, but the royal colleges still insist on a strong component for basic science in the MRCS program. The merits of the distance learning course are that a common, consistent standard is achieved and maintained and the method whereby the trainee obtains knowledge is more acceptable and enjoyable, with a considerable interactive component. With the advent of modern technology, the electronic STEP (e-STEP) course has been developed, which increases flexibility, includes interactive exercises, and stresses the importance of basic scientific knowledge.

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Before trainees can enter HST, they must pass the MRCS examination, which is taken in 3 parts and comprises 2 written papers of multiple-choice questions, a clinical examination, and a viva voce examination, all of which must be passed. Creation of the STEP course has resulted in a higher pass rate compared with the old-style FRCS, which is no longer examined by the English college (the Scottish and Irish colleges are discontinuing this examination in 2002). The MRCS marks the end of BST, and the specialty FRCS is now used to define completion in HST.

After completing BST, trainees compete for HST posts in 1 of 9 specialist areas (general surgery, orthopedics, neurosurgery, cardiothoracic surgery, otolaryngology, urology, plastic surgery, pediatric surgery, and oromaxillofacial surgery). Specialist advisory committees define the syllabi and are accountable to the Joint Committee for Higher Surgical Training, which in turn reports to the royal colleges via the Senate of Surgery. A quinquennial inspection of training posts by members of the specialist advisory committees is well established. At the end of 6 years of recognized training, a certificate of completion of specialist training is awarded provided the intercollegiate specialty FRCS examination has been passed. Rotations through successive posts in the training program are produced by a program director in conjunction with the Regional Higher Surgical Training Committee-the equivalent of the Residency Review Committee in the United States. The rotations are arranged so that the first 2 years include specialty-specific general content and the later years include training in more specialized units.

Academic Departments of Surgery

British medical schools all have an academic department of surgery to lead the teaching and the examination of undergraduates. The university appoints the head of the department, titled professor of surgery, who by convention is a general surgeon, although each has a specialist practice such as upper or lower gastrointestinal surgery, vascular surgery, endocrine surgery, or breast surgery. Tenured surgical staff within these departments are called senior lecturers and are equivalent in clinical status to consultant surgeons within NHS hospitals. In parallel, NHS surgeons working in teaching hospitals are often given the title of honorary senior lecturer in recognition of their role in teaching medical students.

Evolution of Surgical Training

Surgical training has mirrored the evolution of surgery in many respects. Apprentice style surgical training began as far back as the 16th century, and has continuously evolved and grown, particularly rapidly in the last 30 years. The apprenticeship-based structure was updated, following the formation of the royal college, to require fellowship of the royal college of surgeons (FRCS), attained by passing structured exams. In 1993 the system for surgical training in the UK underwent significant alterations under the supervision of Sir Kenneth Calman, chief medical officer for England. This resulted in an annual review of competency progression (ARCP) and inclusion of a logbook to enable review of surgical experience. The initial aim of these ‘Calman reforms’ was to streamline the progression of middle grades in order to produce clinically competent consultants much earlier than in previous years. Satisfactory completion of these elements enabled progression to the next year of training.

In 2005 the surgical training programme was transformed by further national reforms to junior doctor training. The system was termed Modernising Medical Careers (MMC) which constituted a 2-year foundation training programme followed by specialty training. Assessment was by means of a record of in training assessment (RITA). Following this update, the training programme was amended to comply with the European Working Time Directive (EWTD) which, in theory, reduced the number of surgical training hours from approximately 20,000 to 11,520 for each trainee. This has resulted in a standardised and uniform progression from medical school to specialty training.

In 2007 the Intercollegiate Surgical Curriculum Programme (ISCP) was introduced in an attempt to streamline the training process across sub specialties by including competence-based training along with regular, standardised assessment at Foundation level as well as at the beginning, middle and end of specialty training, across four domains. Entering a surgical career at present involves either appointments through fixed-term positions or ‘staff grade’ roles in surgical jobs, or via the training pathway, which is by far the more direct route. This begins after Foundation training (two years) by entering Core Surgical Training (two years), followed by Specialty Training (six years, beginning with the denomination ‘ST3’, after CT 1 and 2), before completion of training (by achieving the certificate of completion of training, CCT). After this, surgeons may apply for a consultant post.

Introduction of the Improving Surgical Training (IST) programme has been the latest change to UK surgical training at participating trusts. The pilot was commenced in 2018 and comprises 60% training time with protected feedback and reflection time, retaining 40% for service provision. It is a joint project between the Royal College of Surgeons of England (RCSEng) and Health Education England (HEE), created in response to the 2013 Shape of Training report by the General Medical Council (GMC). The project is an evidence-based scheme designed to improve job satisfaction amongst trainees by providing more support and protected training time, and inclusion of more technology-driven and simulation-based learning to enhance education. IST began solely for general surgery trainees, but has since expanded to include vascular surgery, urology and trauma and orthopaedics.

The American College of Surgeons

The American College of Surgeons was launched in May 1913 at the fourth Clinical Congress, attended by 4,000 in Washington, DC. Sir Rickman Godlee, MD, FACS (Hon), presented the College with a gavel made from the desk of his uncle, surgeon Joseph Lister, 1st Baron Lister of Lyme Regis, a pioneer of aseptic surgery. Dr. Godlee, president of the Royal College of Surgeons, became the College's first honorary fellow at the meeting.

The requirements for Fellowship in the College were set forth in the first report of Franklin H. Martin, MD, FACS, to the Regents. Fellows were required to submit detailed case records of 50 consecutive major operations they had performed themselves. A motion was made and passed that each Fellow should pledge not to split fees: "Upon my honor as a gentleman, I hereby declare that I will not practice the division of fees, either directly or indirectly, in any manner whatsoever." As Franklin H. Martin, MD, FACS, later described it, fee-splitting is an "abominable practice" involving "the buying and selling of patients, with the highest bidder the purchaser, regardless of his ability." The requirements specified that the signer agreed not to collect fees for others, have others collect them for him, or make "joint fees" related to patient referrals.

Renowned Surgeon Daniel H. Williams, MD, FACS, was the first African American to become a Fellow. The move to accept Dr. a Fellow sparked a fierce debate in which one surgeon warned that his admittance to the College would erode support for the organization in the South. Although Dr. College Admission Requirements Should be Based on Experience, not a Test, Dr. Franklin H. College Director Franklin H. President Woodrow Wilson appointed Franklin H. He became chairman of the group's Medical Committee, which addressed medical problems related to the national defense. Physicians for Military Preparedness to inventory and coordinate civilian medical resources for use in the war effort. The committee, chaired by William J. The four-year-old American College of Surgeons absorbed the now annual Clinical Congress.

As part of its hospital standardization program, first proposed by Ernest A. They would then learn from any failures and how to avoid those situations in the future. On Oct. director, announced the results of the field trials in New York: Only 89 of 692 hospitals met the most basic standards, including some of the most prestigious hospitals in the country.

Several founding members of the College had key roles in organizing field hospitals for the American Expeditionary Force (AEF), the first time the United States sent its military abroad to defend foreign soil. Earlier in the War, College Fellows George Crile, MD, FACS, and Harvey Cushing, MD, FACS, ran a field hospital in France called the Ambulance Américaine, which was organized by Americans in Paris to treat casualties from all nations. entered the War, Dr. Cushing led a crusade to erect a full-scale field hospital in the Boston Common to show the American public the need for military medical preparedness.

Surgery in the United Kingdom and the NHS

Surgery in the United Kingdom (UK) is largely provided through the National Health Service (NHS), a system of health care that has been in existence for more than 50 years. It is estimated that 12 million (20%) of the 59.5 million people in the UK seek some form of private treatment annually, but only 7 million (12%) are covered by medical insurance. Private hospitals rarely provide emergency service, which is almost exclusively provided by the NHS.

Early evidence of surgery in Great Britain is recorded after the arrival of Claudius in 43 AD. Surgical instruments that were recently discovered during an archaeological excavation in a Roman doctor's house in Colchester (the oldest recorded Roman town in England) resemble the instruments used in ancient Egypt. In 1216, a papal edict required that priests not practice surgery lest they shed blood. Consequently, surgery passed from priests to barbers, the more skilled of whom became known as surgeons and were referred to as "leeches." In London in 1300, a Fellowship of Surgeons was established to assess and accredit surgeons. War between England and France during the next 200 years brought about the emergence of the surgeon as a vital part of the King's Army.

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