Are Great Surgeons Born?

REFLECTIONS

Are Great Surgeons Born? Thomas Fysh, MBBS, MRCS, MSc Department of Breast Surgery, Royal Devon and Exeter NHS Foundation Trust, Devon, United Kingdom The assertion that great surgeons are born does not lend itself to a straightforward evidence-based evaluation, not least because there is no binding consensus as to what exactly comprises a great surgeon. Although it is seldom helpful to constrain oneself with definitions, a review of some current literature does reveal common themes. In his leading work on the subject of expertise, Dr K. Anders Ericsson, who has devoted much of his life’s work to this subject (which might, pleasingly, make him an “expert on expertise”), emphasizes this point and describes some ways researchers have tried to identify and explain its constituents. Some come as no surprise, whereas others seem curious and counterintuitive.1 The contention that surgeons are born, however, conjures up images of something a little more ethereal, hinting at a rare talent that cannot be learned and that is ingrained into the DNA. Put like this, the assertion begins to lose credibility, but this view of expertise, formalized many years ago by Sir Francis Galton and the eugenics movement, has endured until recently.2 Of course, from a historical perspective, it certainly was the case that surgical expertise (and for that matter, surgical incompetence) was born. The absence of a “Y” chromosome was a virtual barrier to a surgical career until Eleanor Davies-Colley was admitted to the Royal College of Surgeons of England in the early twentieth century, and it is still the case that female surgeons make up less than 8% of consultants in the United Kingdom and 7% of surgical associate professors in the United States.3,4 Similarly, a privileged background has always been associated with a surgical career and, again today’s surgeons are overwhelmingly drawn from wealthy, well-educated families according to a recent report from the American Association of Medical Colleges, suggesting that even if one’s genes will not necessarily preclude one from a surgical career, it helps to be born into the right socioeconomic circumstances.5 Although these observations should not validate the statement in question completely, it is difficult to ignore the facts, and to this extent at least, it is true that many expert surgeons are “born,” even if they need to be made too. Conversely, some facets of surgery must be learned. Knowledge of anatomy, physiology, pharmacology and so on, as well as technical skill, must all be acquired before any surgical proCorrespondence: Inquiries to Thomas Fysh, MBBS, MRCS, MSc, Department of Breast Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter, Devon EX2 5DW, United Kingdom; fax: ⫹44 (0)1392 402 175; e-mail: [email protected]

cedure is attempted, and it is generally accepted that even these basics will take years to accrue. Furthermore, for students to accomplish this, they must successfully scale one of the most competitive career ladders in existence. This requires a certain amount of latent intelligence, of course, but academic prowess does not correlate well with various objective measures of surgical performance.6,7 This finding complements additional work on outstanding performance by the educational psychologist Arthur Jensen in the early 1980s; above a certain “threshold,” the absolute level of one’s mental ability does not matter and so-called “genius” is not determined by measurable intelligence.8 For a real-life example, consider the success of Albert Einstein. His demonstrably average achievements at school and the Swiss Polytechnic College, from where he finished fourth out of five students in the final diploma, did not predict his later glory; in his own words: “Nobody expected me to lay golden eggs.” Einstein had vision, dedication, and passion such that his early academic record was good enough, but nothing special.9 The same logic has been applied to basketball; Michael Jordan, arguably the finest player in history, is a rather paltry 6 ft 6 inches, which places him below average for height in the National Basketball Association. Jensen himself studied Shakuntala Devi, who multiplied two 13-digit numbers together in under 20 seconds; she actually had an average IQ and scored below average on other mental processing tasks. Furthermore, twin studies and other investigations into IQ, dexterity, and task performance would suggest that these qualities are only partly heritable, and it has been observed repeatedly that pretest differences (often observed in childhood) are soon canceled out after a period of productive learning.10,11 The “raw intelligence” required to become a surgical expert (one can almost hear the physicians giggling), is not born, after all. And yet, it is obvious to most trainers that some students flourish early and are immediately comfortable in the surgical environment; equally obvious are those who struggle. To determine whether surgical expertise is innate or whether it can be learned, we must identify first those qualities, talents, and attributes that are considered crucial for its achievement. Both the American College of Surgeons and the Medical Education England (MEE) specifications for higher surgical training list more than a dozen core qualities, such as clinical excellence, effective communication, probity, commitment to specialty, life-long learning, and so on, which are considered

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mandatory for the practicing surgeon to possess.12,13 One might trace these components back to the fundamental domains of knowledge, skills, and professionalism, leading to the logical conclusion (if we trust the list) that a great surgeon might have his or her roots in each of them. Critics of such targets might argue that by attempting to reduce the notion of expertise to an inventory, one loses the essence of what it is; surely, the qualities of a great surgeon are more difficult to define than this? This leads on to the intriguing question of who is best placed to judge the attributes of a “great” surgeon: Should we turn to the esteemed colleague, the patient whose life was saved, the inspired junior doctor, or conversely, the ignored intern, the bullied secretary, or medical litigant? In their work, “Cultivating a Thinking Surgeon,” de Cossart and Fish devote much time to this question, drawing on diverse evidence and opinion. Their conclusion is, predictably, that greatness cannot be reduced to a pithy sound bite but that covers more than clinical ability and knowledge; the great surgeon is devoted, passionate, thoughtful, and altruistic, as well as knowledgeable and skillful.14 Of course, nobody could claim to have “the exclusive” on what constitutes surgical greatness, and we could all legitimately add plenty of other adjectives to our own lists and no guarantee of consensus; one persons “great surgeon” could easily be another’s blundering incompetent. But that is not to say that surgical expertise (if not “greatness,” which is possibly a little too abstract a concept to pin down) cannot be acquired, and despite the misgivings of de Cossart, Fish, and others, listing criteria for selection into medical training is a technique employed widely for candidate selection. It seems logical that these qualities might be related to the potential for expertise. The crux of the relationship is that to produce an expert at the end of training (if, indeed, one’s training can ever truly “end”), then it would seem to be sensible to identify those personality traits observable among current experts in that field, and to select similar students. Indeed, it has been a popular topic of research to try to define the qualities of the expert and over the years, and some enduring observations have been made. These are well described by Feltovitch and Anders Ericsson, who summarize the main points: Expertise is limited in its scope,15 knowledge and content are crucial (but, again localized to domain), and experts work with large “cognitive units.” In their seminal paper on the matter, Chase and Simon called this “chunking” and described how expert chess players could recall the positions of chess pieces on a board better than novices— but only if they were from real games.16 Applied to medicine, consultants are more effective diagnosticians because they have large, wellstructured, efficient, and easily accessible memory stores of clinical knowledge.17 Furthermore, experts are capable of abstraction and forward-thinking on account of the depth of their knowledge,18 can automate their work routinely, are highly selective in identifying relevant information, and perhaps crucially, tend to be adaptive.1 It would be worth sounding a note of caution to those who would reproduce all the “qualities” of the expert. Chi’s description of the characteristics of experts is not entirely flattering; experts are sometimes arrogant and over268

estimate their ability; they are sometimes careless and more prone to “glossing over” than others; and they are often inflexible and are usually biased to their own methodology/opinion and this sometimes leads to catastrophic outcomes.6,19 For popular examples in medicine, one need only turn to cases of medical malpractice, such as that of Sir Roy Meadows, the discredited UK consultant physician whose “expert” evidence on cot death led to the wrongful conviction of many women for infanticide. Important though these findings are, they pertain largely to the acquisition and use of knowledge and even knowing the qualities of an expert does not say much about their provenance. Various models of expertise have been proposed, but surgical expertise seems particularly difficult to investigate, not least because no single facet of surgery is like any other; researchers need convenient, workable subject matter, but this bypasses the very complexity of surgical expertise, which is evolutionary and adaptive. Academics have used dermatologic conditions, radiography, and electrocardiogram interpretation to look into diagnostic proficiency for precisely this reason, but in the field of surgery, we have the added difficulty that much of an individual’s expertise is concerned with outcome as well as diagnosis. Anders Ericsson suggests that in “surgery, treatment success can be measured by indicators such as death, complications or blood loss.” To this, he might add speed of surgery, economy of movement, and so on, but in a cautious departure from Anders Ericsson’s wisdom, I suggest that this approach is flawed in the real world. Whereas it could be argued that most of these parameters will improve with expertise, it may be the case that the very finest surgeons are those with the higher death rates, complication rates, longer operating times, and so on, precisely because these surgeons must perform the most demanding operations. It is equally plausible that poorer surgeons may only choose straightforward, routine cases and, as a result, seem to do rather well. At the other end of the scale, how does one measure the expertise of a surgeon who leaves a patient to die peacefully in a side room with his family instead during a futile operation? The objective outcome experiments, it could be argued, are valid for modeling technical competence, but this differs from surgical expertise or greatness. One might also take note of work by Klein on natural decision making, who describes how reallife processes are infinitely more complex, ill-defined, and unpredictable than contrived experiments and that research on expertise should be (but often is not) carried out in context.20,21 Another approach, which seems less controversial, is to use cohorts of established experts and compare their performance with novices. This is not without potential difficulty (how experts are picked, covariance, causality ascription, etc) but with a little common sense, some convincing results have been achieved. Traditional models of expertise, such as those proposed by de Groot, Simon, Chase, Chi, and others, have emphasized the importance of extended professional experience. This is described as “sustained, deliberate practice” by Anders Ericsson and is the source of the often quoted “10 years” or “10,000 hours” experience required before expertise is achieved. This is

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commonly found within the academic literature on the topic and has recently seen a revival in popularity in respect of the European Working Time Directive debate under which European workers (including trainee surgeons) are limited to working a 48-hour week, and indeed “Libby’s Law” that had a similar effect on the hours of United States residents. Although de Groot’s work is certainly intriguing, and suggests that expertise is largely a matter of pattern recognition, experience, and acquired knowledge, we would do well to remember that he was describing aptitude in chess.22 This does fit the model well, possibly because it is a limited and static domain; other areas of expertise to have been convincingly modeled in this way include sporting, musical, and artistic prowess.23 The arguments and examples put forward by de Groot, Chi, Gladwell, and others are compelling but these fields hardly seem comparable with surgery, and indeed, de Groot’s work on problem solving and later research into the role of knowledge recall as a predictor for expertise was not observed in medicine—in fact, final year students often outperform experts in many these tasks,24 and older surgeons consistently performed less well on knowledge tests than younger colleagues.25 The fields that do fit the paradigm of extended professional experience tend to have limited confines (eg, the rules of football do not change, every chess board is identical, and so on), have easily defined outcomes (eg, win, lose, or draw), and that they have little to do, in their execution at least, with other people. Indeed, they seem to be largely concerned with the mastery of knowledge and skill. It follows that there would be thousands of virtuoso violinists if we all started to play at the age of 4 and practiced 3 times a day, and there are echoes of this within the field of surgery. Whereas previously, competence was largely a measure of experience, it is now recognized that some individuals can achieve competence despite relatively little experience and, conversely, some require much more exposure to achieve the same. The application of this belief is evident in the work-based assessments founded on work by Norcini,26 which emphasize the student’s ability to perform a particular procedure rather than the number of those procedures performed. But although some individuals may take a little longer to acquire knowledge and skills than others, the requirement for expertise is that they do eventually get there and not their learning velocity per se. Moreover, the received wisdom that surgeons must be highly gifted in this domain does not seem to be true, and it has been shown in several studies that surgeons and other groups have similar levels of manual dexterity in objective and unfamiliar settings,27,28 and that, in any case, manual dexterity does not correlate with surgical performance.29 Some evidence that innate visuospatial ability correlates with surgical performance emerged following a task observation study by Kyle Wenzel. Students with higher pretest visuospatial scores were better able to perform a surgical task than others. But in a finding reminiscent of the twin studies on IQ, it was found that the differences are superficial and arguably, irrelevant; after a 10-minute instruction and feedback session, performances were equal throughout the cohort.30 It would seem then, that operative skill can be learned, and prob-

ably by most of us. This is comfort to the surgical curriculum designers but again, surgical educational theorists such as de Cossart have trouble with the advent of the “tick box” professional, arguing that expertise must push beyond the realms of competency and that it is not enough to produce a generation of good technicians. Surgical experts are reflective professionals who adapt, learn, and improve, after all.1 Proponents of competency-based assessments would argue that they should not be taken in isolation and that, of course, there is much more to being an expert surgeon than clinical and operative skill. Indeed, even if we cannot pinpoint exactly what an expert surgeon is, we can be sure that he/she is a good deal more than a great technician. The classic model of expertise does seem to ignore much of what being a surgeon is about; here, we need to consider what the surgical expert has beyond from knowledge and skill. The “four-stage competency” model sometimes ascribed to Maslow describes a cycle by which competency is thought to be achieved. The cycle from unconscious incompetence to conscious competence continues and evolves until the level of expertise. Others have proposed a fifth stage to the cycle of “reflective competence,” or “metacognition” as Flavell put it.31 Although it is unlikely that this model was actually conceived of by Maslow (despite wide accreditation to the contrary), it was he who suggested that motivation is required to enter into the cycle, and this was considered to be of paramount importance in the acquisition of expertise. Indeed, this occupied much of his life’s work, and again, we are reminded of the message that latent ability is nothing without motivation. He argued that this idea is derived from circumstance rather than genetics.32 Maslow’s observation has been developed extensively by others and in his consideration of the phenomenon of why expertise is often observed in clusters. Coyle described how Russian gymnasts, Korean golfers, and others have excelled throughout history through social “scaffolding,” the creation of an environment of excellence and through what he calls “deep practice.” He argues that greatness is not born and that through motivation (although he places less emphasis on this that Maslow, and replaces it with self-discipline), effective practice and in particular, identifying the optimum distance between what needs to be learned and what can be learned, virtually anyone can do it. This particular work is an interpretation of previous educational theories and is particularly reminiscent of Vygotsky’s ideas of the zone of proximal development, whom he quotes extensively. Coyle renames this “the sweet spot” and describes a video in which a young girl practices the clarinet in such a way that a phenomenal learning momentum is generated; he argued that she achieved a week’s worth of practice in 1 hour.33 He goes on to describe how clusters of expertise generate and perpetuate themselves. These so-called “hot beds” of learning are derived from Lave and Wenger’s “communities of practice,”34 and again, we are reminded of Anders Ericsson and Chi’s work on the characteristics of experts. They argued that expertise cannot

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not be achieved in isolation and that an expert is one who is an active participant within his field; one who pushes at its boundaries.18,19 For those who would define experts as those esteemed by their peers, it is incongruous that they could work in isolation. Again, these arguments have the feel of nurture rather than nature about them. Nonetheless, any surgical trainee will testify to the fact that not all consultants are equal; although for the purposes of research, most consultant surgeons who take part in such experiments are considered “experts” by virtue of their title, some surgeons stand apart from the crowd. It should be given that consultant surgeons are safe and effective surgeons, but the assertion that “great surgeons are born” hints at this subcohort of “ultraprofessionals”—perhaps these are the “thinking surgeons” referred to by de Cossart and Fish. Do these individuals possess something inherently unlearnable or are they simply more motivated, more interested, more inquisitive, and as a consequence, harder working and higher achieving? And if so, where does this come from? Let us return to Maslow. His observation that motivation is derived from circumstance leads to another fascinating but possibly taboo topic in the development of expertise, namely, luck. Being in the right place at the right time has underpinned some of the finest “achievements” in history; it is believed widely that if William of Normandy had been able to sail on Britain before October 1066, King Harold’s army would have been well situated to beat him—as it happened, William could not sail in the summer because of the adverse weather conditions, and the rest is history. For a less controversial example, consider whether anyone would anyone would have heard of Jamie Oliver had he not been working a particular shift in London’s River Café one day while a BBC film crew were working on another project. This is unfair, of course, and in his book “Outliers,” Malcolm Gladwell would argue that luck, or more accurately, “opportunity” is presented to most of us at some point; the outliers are those who make the most of it.23 If we turn to the “Talent Project” by Bloom in 1985, opportunity is replaced by circumstance.35 When studying the background of various high achievers, he was surprised to find that the group was not composed of exceptionally gifted individuals but, as he puts it, “exceptional conditions,” which were later summarized by Sosniak as opportunity, authenticity, and social support,36 again suggesting that high achievement and by extension, expertise and perhaps greatness, can be taught and learned by almost anyone with reasonable (but not exceptional) intellect, provided the conditions are favorable. Sir Francis Galton might be considered something of a dinosaur by today’s standards, but he did, at least, identify some of the core constituents of surgical expertise. But although he accredited “knowledge, zeal, and hard work” to one’s genome, it would be intriguing to hear his opinion on the role of circumstance, opportunity, and education given his own highly privileged start in life— one who surely epitomized Bloom’s “exceptional conditions.” 270

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