The Next Faithful Step

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THE LEARNING CURVE: Like everyone else, surgeons need practice. That's where you come in.

Atul Gawande, The New Yorker - January 8, 2002


  1. Surgeons don’t believe in talent.  They believe in practice.   

  2. This practice comes at a cost to the patient.  
    1. The only way for a surgeon to learn is to practice  
    2. When you practice you make mistakes  
    3. When surgeons make mistakes, people get hurt  
    4. So the only way for surgeons to learn is to hurt people  
    5. This should create a tremendous humility where the surgeon is beholden to the patient  

Not everyone appreciates the attractions of surgery. When you are a medical student in the operating room for the first time, and you see the surgeon press the scalpel to someone's body and open it like a piece of fruit, you either shudder in horror or gape in awe. I gaped. It was not just the blood and guts that enthralled me. It was also the idea that a person, a mere mortal, would have the confidence to wield that scalpel in the first place. 

There is a saying about surgeons: "Sometimes wrong; never in doubt." This is meant as a reproof, but to me it seemed their strength. Every day, surgeons are faced with uncertainties. Information is inadequate; the science is ambiguous; one's knowledge and abilities are never perfect. Even with the simplest operation, it cannot be taken for granted that a patient will come through better off-or even alive. Standing at the operating table, I wondered how the surgeon knew that all the steps would go as planned, that bleeding would be controlled and infection would not set in and organs would not be injured. He didn't, of course. But he cut anyway.

Later, while still a student, I was allowed to make an incision myself. The surgeon drew a six-inch dotted line with a marking pen across an anesthetized patient's abdomen and then, to my surprise, had the nurse hand me the knife. It was still warm from the autoclave. The surgeon had me stretch the skin taut with the thumb and forefinger of my free hand. He told me to make one smooth slice down to the fat. I put the belly of the blade to the skin and cut. The experience was odd and addictive, mixing exhilaration from the calculated violence of the act, anxiety about getting it right, and a righteous faith that it was somehow for the person's good. There was also the slightly nauseating feeling of finding that it took more force than I'd realized. (Skin is thick and springy, and on my first pass I did not go nearly deep enough; I had to cut twice to get through.) The moment made me want to be a surgeon-not an amateur handed the knife for a brief moment but someone with the confidence and ability to proceed as if it were routine.

A resident begins, however, with none of this air of mastery-only an overpowering instinct against doing anything like pressing a knife against flesh or jabbing a needle into someone's chest. On my first day as a surgical resident, I was assigned to the emergency room. Among my first patients was a skinny, dark-haired woman in her late twenties who hobbled in, teeth gritted, with a two-foot-long wooden chair leg somehow nailed to the bottom of her foot. She explained that a kitchen chair had collapsed under her and, as she leaped up to keep from falling, her bare foot had stomped down on a three-inch screw sticking out of one of the chair legs. I tried very hard to look like someone who had not got his medical diploma just the week before. Instead, I was determined to be nonchalant, the kind of guy who had seen this sort of thing a hundred times before. I inspected her foot, and could see that the screw was embedded in the bone at the base of her big toe. There was no bleeding and, as far as I could feel, no fracture.

"Wow, that must hurt," I blurted out, idiotically.

The obvious thing to do was give her a tetanus shot and pull out the screw. I ordered the tetanus shot, but I began to have doubts about pulling out the screw. Suppose she bled? Or suppose I fractured her foot? Or something worse? I excused myself and tracked down Dr. W., the senior surgeon on duty. I found him tending to a car-crash victim. The patient was a mess, and the floor was covered with blood. People were shouting. It was not a good time to ask questions.

I ordered an X-ray. I figured it would buy time and let me check my amateur impression that she didn't have a fracture. Sure enough, getting the X-ray took about an hour, and it showed no fracture-just a common screw embedded, the radiologist said, "in the head of the first metatarsal." I showed the patient the X-ray. "You see, the screw's embedded in the head of the first metatarsal," I said. And the plan? she wanted to know. Ah, yes, the plan.

I went to find Dr. W. He was still busy with the crash victim, but I was able to interrupt to show him the X-ray. He chuckled at the sight of it and asked me what I wanted to do. "Pull the screw out?" I ventured. "Yes," he said, by which he meant "Duh." He made sure I'd given the patient a tetanus shot and then shooed me away.

Back in the examining room, I told her that I would pull the screw out, prepared for her to say something like "You?" Instead she said, "O.K., Doctor." At first, I had her sitting on the exam table, dangling her leg off the side. But that didn't look as if it would work. Eventually, I had her lie with her foot jutting off the table end, the board poking out into the air. With every move, her pain increased. I injected a local anesthetic where the screw had gone in and that helped a little. Now I grabbed her foot in one hand, the board in the other, and for a moment I froze. Could I really do this? Who was I to presume? 

Finally, I gave her a one-two-three and pulled, gingerly at first and then hard. She groaned. The screw wasn't budging. I twisted, and abruptly it came free. There was no bleeding. I washed the wound out, and she found she could walk. I warned her of the risks of infection and the signs to look for. Her gratitude was immense and flattering, like the lion's for the mouse-and that night I went home elated.

In surgery, as in anything else, skill, judgment, and confidence are learned through experience, haltingly and humiliatingly. Like the tennis player and the oboist and the guy who fixes hard drives, we need practice to get good at what we do. There is one difference in medicine, though: we practice on people.  

Surgeons, as a group, … believe in practice, not talent. People often assume that you have to have great hands to become a surgeon, but it's not true. When I interviewed to get into surgery programs, no one made me sew or take a dexterity test or checked to see if my hands were steady. You do not even need all ten fingers to be accepted. To be sure, talent helps. Professors say that every two or three years they'll see someone truly gifted come through a program-someone who picks up complex manual skills unusually quickly, sees tissue planes before others do, anticipates trouble before it happens. Nonetheless, attending surgeons say that what's most important to them is finding people who are conscientious, industrious, and boneheaded enough to keep at practicing this one difficult thing day and night for years on end. As a former residency director put it to me, given a choice between a Ph.D. who had cloned a gene and a sculptor, he'd pick the Ph.D. every time. Sure, he said, he'd bet on the sculptor's being more physically talented; but he'd bet on the Ph.D.'s being less "flaky." And in the end that matters more. Skill, surgeons believe, can be taught; tenacity cannot. It's an odd approach to recruitment, but it continues all the way up the ranks, even in top surgery departments. They start with minions with no experience in surgery, spend years training them, and then take most of their faculty from these same homegrown ranks.

And it works. There have now been many studies of elite performers-concert violinists, chess grand masters, professional ice-skaters, mathematicians, and so forth-and the biggest difference researchers find between them and lesser performers is the amount of deliberate practice they've accumulated. Indeed, the most important talent may be the talent for practice itself. K. Anders Ericsson, a cognitive psychologist and an expert on performance, notes that the most important role that innate factors play may be in a person's willingness to engage in sustained training. He has found, for example, that top performers dislike practicing just as much as others do. (That's why, for example, athletes and musicians usually quit practicing when they retire.) But, more than others, they have the will to keep at it anyway. 

Commentary:  This is the professor.  I want to describe for you why I had you read this.
The only way a surgeon learns is by making mistakes – mistakes on real, live human beings.
So that should create a certain kind of humility because the surgeon is beholden to the people who paid the price for her learning.

Ministry is like surgery.  The only way to learn is to practice, and to learn from your mistakes.
But you make those mistakes on real, live human beings.
So that should create a degree of humility for you.
You cannot afford to hide from your mistakes; you have to learn from them. 
Someone else paid the price for your learning.
Embrace your failings and learn from your mistakes.