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Outside the Ivory Towers

Shin, Alexander, Y., MD

Techniques in Hand & Upper Extremity Surgery: June 2018 - Volume 22 - Issue 2 - p 37–38
doi: 10.1097/BTH.0000000000000194

Mayo Clinic, Rochester, MN

Conflicts of Interest and Source of Funding: The author reports no conflicts of interest and no source of funding.

Address correspondence and reprint requests to Alexander Y. Shin, MD, Mayo Clinic, Rochester, MN 55905. E-mail:

I was recently at a major Orthopedic Surgery meeting and was discussing with several colleagues the issues of fellowship and resident education, when one of my colleagues told me that things were significantly different “Outside the Ivory Towers,” and how education “within the Ivory Towers” should change to reflect the needs of the “real world,” in particular the education of billing and how to run a private practice. I started to ponder the etymology of “ivory tower” and how it related to hand training.

The earliest use of the term “Ivory Tower” originates from the Songs of Solomon, a book of the Bible. In chapter 7, verse 4, Solomon extols the beauty of his beloved—“Thy neck is as a tower of ivory….”1 Subsequently, the term has been found in the epithets for Mary in the 16th century Litany of the Blessed Virgin Mary, where it is written in Latin as “turris eburnea” (tower of ivory).

The modern use of “Ivory Towers” has been attributed to a French literary critic and author, Charles Augustine Stainte-Beauve.2 In 1837, he penned a poem “Pensees d’Aout a M. Villemain,” and used the term “tour d’ivoire” to describe the contrasts of the aloof and withdrawn Alfred de Vigny to a more socially engaged Victor Hugo. In Stainte-Beauve’s poem, he writes “Vigny, the more secretive, like he was in his ivory tower, returning before midday.”

The term “Ivory Tower” was Sainte-Beuve’s most famous phrase and at the turn of the 19th century became quite familiar, although its meaning remained vague, as it had developed a negative connotation.

The term was given a jolt in 1917, when Henry James’ unfinished novel, The Ivory Tower, was posthumously published.3 Interestingly, this novel had nothing to do with the ivory tower. At the end of the 19th and beginning of the 20th century, the term was largely used with respect to artistic creations and artists/poets. The Ivory Tower became a term describing a safe place where poets and artists could have the freedom to express themselves. By the mid-20th century, the Ivory Tower term was associated with Universities, emphasizing a safe place for students to engage and discuss issues without retribution, especially controversial issues surrounding postwar activities.1 Very quickly the term was used to describe science and medicine, in particular academic medicine.

Webster’s Dictionary definition is 2-fold4: (1) an impractical often escapist attitude marked by aloof lack of concern with or interest in practical matters or urgent problems, and (2) a secluded place that affords the meaning of treating practical issues with an impractical often escapist attitude, especially a place of learning. Both relate to elitist, uncaring, aloof places with no concern for practical matters.

The etymology of the “ivory tower” evolved from a description of a beautiful neck, to a reclusive place of retreat, to a place of free thought/expression for artists, to describing the aloof attitudes of academia toward the nonacademic world. So how does this affect the education of fellows with respect to “real world issues” of billing, coding, and running a private practice? The hand surgery fellowship is in most instances a precious year to develop keen history taking and physical examination techniques, hone surgical skills, and learn from the experiences and mistakes of mentors. The vast spectrum of pathology and surgical practice of hand surgery makes it impossible to cover all aspects in a single year, yet in a career. Because of time constraints, some fellowships have focused on only regional areas of hand surgery (shoulder/elbow/hand), whereas others have relinquished other areas (microsurgery, congenital, peripheral nerve).

In addressing the issues “Outside the Ivory Towers,” we must ask critical questions: do graduates of hand fellowship programs say “I wish I learned more ICD-10 coding during fellowship,” or do they say “I wish I seen more surgeries and patients?” Some fellowship directors would argue that there is not enough time to include practice management and billing/coding. As a majority of hand surgery fellowships are conducted at University-based programs, the ability to integrate the “real world” is not always feasible and may not always be applicable to the fellow.

While the engagement of “real world” surgeons in fellowship education is needed to balance fellow education, the confines of a year of education may not make it possible. Thinking outside the traditional fellowship training and involving our professional societies may be a more attractive alternative. Fellow and resident instructional course lectures on practice management or billing strategies by “real world” surgeons at our national professional societies is necessary. The concept of Ivory Tower medicine needs to change to one where the goals are patient centric and reflective of those of the Hippocratic Oath. There is definitely a need to balance academic/surgical education with “real world” issues—the challenge will be how to do this.

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1. Shapin S. The Ivory Tower: history of a figure of speech and its cultural issues. Br Soc Hist Sci. 2012;45:1–27.
2. Sainte-Beuve CA. Poesies completes de Sainte-Beauve. Paris: Charpentier; 1869:374.
3. James H. The Ivory Tower. London: W.Collins; 1917.
4. “Ivory Tower.” Merriam-Webster. March 17, 2018.
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