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Education of a Knife

Atul Gawande, From "Complications: A Surgeon’s Notes on an Imperfect Science" (New York: Picador, 2002)

Background: Atul Gawande is a surgeon who wrote a series of articles in The New Yorker about his experiences as a doctor. Those articles then became an award-winning book. The first chapter is about how one learns to be a doctor. It makes some crucial points that resonate for the experience of learning ministry. The following is an outline of his key points in the chapter, followed by quotations that capture his words. 

  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

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: it is people we practice upon. (p. 18)

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. (p. 19)

The moral burden of practicing on people is always with us, but for the most part unspoken. Before each operation, I go over to the pre-operative holding area in my scrubs and introduce myself to the patient. I do it the same way every time. “Hello, I’m Dr. Gawande. I’m one of the surgical residents, and I’ll be assisting your surgeon.” That is pretty much all I say on the subject. I extend my hand and give a smile. I ask the patient if everything is OK so far. We chat. I answer questions. Very occasionally, patients are taken aback. “No resident is doing my surgery,” they say. I try to reassure. “Not to worry. I just assist,” I say. “The attending surgeon is always in charge.”

None of this is exactly a lie. The attending is in charge, and a resident knows better than to forget that…Yet to say I just assist remains a kind of subterfuge. I wasn’t merely an extra pair of hands, after all. Otherwise, why did I hold the knife? Why did I stand on the operator’s side of the table? Why was it raised to my six-feet-plus height? I was there to help, yes, but I was there to practice, too. (p. 22)

We want perfection without practice. Yet everyone is harmed if no one is trained for the future. (p. 24)

To fail to adopt new techniques would mean denying patients meaningful medical advances. Yet the perils of the learning are inescapable. [Gawande then describes a new surgical technique that doctors used for heart surgery.] The annual death rate after a successful procedure [using the new method] was less than a quarter that after the [old method], resulting in a life expectancy of sixty-three years instead of forty-seven. But the price of learning to do it was appalling. In the first seventy operations [under the new method], the doctors had a 25 percent surgical death rate, compared to just six percent [under the old method]….Only with time did they master it: in the next hundred operations [under the new method], just five babies died. As patients, we want both expertise and progress. What nobody wants to face is that these are contradictory desires. In the words of one British public report, ‘There should be no learning curve as far as patient safety is concerned.’ But that is entirely wishful thinking.” (p. 26-28)

“In a sense, then, the physician’s dodge is inevitable. Learning must be stolen…Learning is necessary but causes harm.” (p. 32)