I’ve been a surgeon for eight years. For the past couple of them, my performance in the operating room has reached a plateau. I’d like to think it’s a good thing—I’ve arrived at my professional peak. But mainly it seems as if I’ve just stopped getting better.
During the first two or three years in practice, your skills seem to improve almost daily. It’s not about hand-eye coördination—you have that down halfway through your residency. As one of my professors once explained, doing surgery is no more physically difficult than writing in cursive. Surgical mastery is about familiarity and judgment. You learn the problems that can occur during a particular procedure or with a particular condition, and you learn how to either prevent or respond to those problems.
Say you’ve got a patient who needs surgery for appendicitis. These days, surgeons will typically do a laparoscopic appendectomy. You slide a small camera—a laparoscope—into the abdomen through a quarter-inch incision near the belly button, insert a long grasper through an incision beneath the waistline, and push a device for stapling and cutting through an incision in the left lower abdomen. Use the grasper to pick up the finger-size appendix, fire the stapler across its base and across the vessels feeding it, drop the severed organ into a plastic bag, and pull it out. Close up, and you’re done. That’s how you like it to go, anyway. But often it doesn’t.
Even before you start, you need to make some judgments. Unusual anatomy, severe obesity, or internal scars from previous abdominal surgery could make it difficult to get the camera in safely; you don’t want to poke it into a loop of intestine. You have to decide which camera-insertion method to use—there’s a range of options—or whether to abandon the high-tech approach and do the operation the traditional way, with a wide-open incision that lets you see everything directly. If you do get your camera and instruments inside, you may have trouble grasping the appendix. Infection turns it into a fat, bloody, inflamed worm that sticks to everything around it—bowel, blood vessels, an ovary, the pelvic sidewall—and to free it you have to choose from a variety of tools and techniques. You can use a long cotton-tipped instrument to try to push the surrounding attachments away. You can use electrocautery, a hook, a pair of scissors, a sharp-tip dissector, a blunt-tip dissector, a right-angle dissector, or a suction device. You can adjust the operating table so that the patient’s head is down and his feet are up, allowing gravity to pull the viscera in the right direction. Or you can just grab whatever part of the appendix is visible and pull really hard.
Once you have the little organ in view, you may find that appendicitis was the wrong diagnosis. It might be a tumor of the appendix, Crohn’s disease, or an ovarian condition that happened to have inflamed the nearby appendix. Then you’d have to decide whether you need additional equipment or personnel—maybe it’s time to enlist another surgeon.
Over time, you learn how to head off problems, and, when you can’t, you arrive at solutions with less fumbling and more assurance. After eight years, I’ve performed more than two thousand operations. Three-quarters have involved my specialty, endocrine surgery—surgery for endocrine organs such as the thyroid, the parathyroid, and the adrenal glands. The rest have involved everything from simple biopsies to colon cancer. For my specialized cases, I’ve come to know most of the serious difficulties that could arise, and have worked out solutions. For the others, I’ve gained confidence in my ability to handle a wide range of situations, and to improvise when necessary.
As I went along, I compared my results against national data, and I began beating the averages. My rates of complications moved steadily lower and lower. And then, a couple of years ago, they didn’t. It started to seem that the only direction things could go from here was the wrong one.
Maybe this is what happens when you turn forty-five. Surgery is, at least, a relatively late-peaking career. It’s not like mathematics or baseball or pop music, where your best work is often behind you by the time you’re thirty. Jobs that involve the complexities of people or nature seem to take the longest to master: the average age at which S. & P. 500 chief executive officers are hired is fifty-two, and the age of maximum productivity for geologists, one study estimated, is around fifty-four. Surgeons apparently fall somewhere between the extremes, requiring both physical stamina and the judgment that comes with experience. Apparently, I’d arrived at that middle point.
It wouldn’t have been the first time I’d hit a plateau. I grew up in Ohio, and when I was in high school I hoped to become a serious tennis player. But I peaked at seventeen. That was the year that Danny Trevas and I climbed to the top tier for doubles in the Ohio Valley. I qualified to play singles in a couple of national tournaments, only to be smothered in the first round both times. The kids at that level were playing a different game than I was. At Stanford, where I went to college, the tennis team ranked No. 1 in the nation, and I had no chance of being picked. That meant spending the past twenty-five years trying to slow the steady decline of my game.
I still love getting out on the court on a warm summer day, swinging a racquet strung to fifty-six pounds of tension at a two-ounce felt-covered sphere, and trying for those increasingly elusive moments when my racquet feels like an extension of my arm, and my legs are putting me exactly where the ball is going to be. But I came to accept that I’d never be remotely as good as I was when I was seventeen. In the hope of not losing my game altogether, I play when I can. I often bring my racquet on trips, for instance, and look for time to squeeze in a match.
One July day a couple of years ago, when I was at a medical meeting in Nantucket, I had an afternoon free and went looking for someone to hit with. I found a local tennis club and asked if there was anyone who wanted to play. There wasn’t. I saw that there was a ball machine, and I asked the club pro if I could use it to practice ground strokes. He told me that it was for members only. But I could pay for a lesson and hit with him.
He was in his early twenties, a recent graduate who’d played on his college team. We hit back and forth for a while. He went easy on me at first, and then started running me around. I served a few points, and the tennis coach in him came out. You know, he said, you could get more power from your serve.
I was dubious. My serve had always been the best part of my game. But I listened. He had me pay attention to my feet as I served, and I gradually recognized that my legs weren’t really underneath me when I swung my racquet up into the air. My right leg dragged a few inches behind my body, reducing my power. With a few minutes of tinkering, he’d added at least ten miles an hour to my serve. I was serving harder than I ever had in my life.
Not long afterward, I watched Rafael Nadal play a tournament match on the Tennis Channel. The camera flashed to his coach, and the obvious struck me as interesting: even Rafael Nadal has a coach. Nearly every élite tennis player in the world does. Professional athletes use coaches to make sure they are as good as they can be.
But doctors don’t. I’d paid to have a kid just out of college look at my serve. So why did I find it inconceivable to pay someone to come into my operating room and coach me on my surgical technique?
What we think of as coaching was, sports historians say, a distinctly American development. During the nineteenth century, Britain had the more avid sporting culture; its leisure classes went in for games like cricket, golf, and soccer. But the aristocratic origins produced an ethos of amateurism: you didn’t want to seem to be trying too hard. For the Brits, coaching, even practicing, was, well, unsporting. In America, a more competitive and entrepreneurial spirit took hold. In 1875, Harvard and Yale played one of the nation’s first American-rules football games. Yale soon employed a head coach for the team, the legendary Walter Camp. He established position coaches for individual player development, maintained detailed performance records for each player, and pre-planned every game. Harvard preferred the British approach to sports. In those first three decades, it beat Yale only four times.
The concept of a coach is slippery. Coaches are not teachers, but they teach. They’re not your boss—in professional tennis, golf, and skating, the athlete hires and fires the coach—but they can be bossy. They don’t even have to be good at the sport. The famous Olympic gymnastics coach Bela Karolyi couldn’t do a split if his life depended on it. Mainly, they observe, they judge, and they guide.
Coaches are like editors, another slippery invention. Consider Maxwell Perkins, the great Scribner’s editor, who found, nurtured, and published such writers as F. Scott Fitzgerald, Ernest Hemingway, and Thomas Wolfe. “Perkins has the intangible faculty of giving you confidence in yourself and the book you are writing,” one of his writers said in a New Yorker Profile from 1944. “He never tells you what to do,” another writer said. “Instead, he suggests to you, in an extraordinarily inarticulate fashion, what you want to do yourself.”
The coaching model is different from the traditional conception of pedagogy, where there’s a presumption that, after a certain point, the student no longer needs instruction. You graduate. You’re done. You can go the rest of the way yourself. This is how élite musicians are taught. Barbara Lourie Sand’s book “Teaching Genius” describes the methods of the legendary Juilliard violin instructor Dorothy DeLay. DeLay was a Perkins-like figure who trained an amazing roster of late-twentieth-century virtuosos, including Itzhak Perlman, Nigel Kennedy, Midori, and Sarah Chang. They came to the Juilliard School at a young age—usually after they’d demonstrated talent but reached the limits of what local teachers could offer. They studied with DeLay for a number of years, and then they graduated, launched like ships leaving drydock. She saw her role as preparing them to make their way without her.
Itzhak Perlman, for instance, arrived at Juilliard, in 1959, at the age of thirteen, and studied there for eight years, working with both DeLay and Ivan Galamian, another revered instructor. Among the key things he learned were discipline, a broad repertoire, and the exigencies of technique. “All DeLay’s students, big or little, have to do their scales, their arpeggios, their études, their Bach, their concertos, and so on,” Sand writes. “By the time they reach their teens, they are expected to be practicing a minimum of five hours a day.” DeLay also taught them to try new and difficult things, to perform without fear. She expanded their sense of possibility. Perlman, disabled by polio, couldn’t play the violin standing, and DeLay was one of the few who were convinced that he could have a concert career. DeLay was, her biographer observed, “basically in the business of teaching her pupils how to think, and to trust their ability to do so effectively.” Musical expertise meant not needing to be coached.
Doctors understand expertise in the same way. Knowledge of disease and the science of treatment are always evolving. We have to keep developing our capabilities and avoid falling behind. So the training inculcates an ethic of perfectionism. Expertise is thought to be not a static condition but one that doctors must build and sustain for themselves.
Coaching in pro sports proceeds from a starkly different premise: it considers the teaching model naïve about our human capacity for self-perfection. It holds that, no matter how well prepared people are in their formative years, few can achieve and maintain their best performance on their own. One of these views, it seemed to me, had to be wrong. So I called Itzhak Perlman to find out what he thought.
I asked him why concert violinists didn’t have coaches, the way top athletes did. He said that he didn’t know, but that it had always seemed a mistake to him. He had enjoyed the services of a coach all along.
He had a coach? “I was very, very lucky,” Perlman said. His wife, Toby, whom he’d known at Juilliard, was a concert-level violinist, and he’d relied on her for the past forty years. “The great challenge in performing is listening to yourself,” he said. “Your physicality, the sensation that you have as you play the violin, interferes with your accuracy of listening.” What violinists perceive is often quite different from what audiences perceive.
“My wife always says that I don’t really know how I play,” he told me. “She is an extra ear.” She’d tell him if a passage was too fast or too tight or too mechanical—if there was something that needed fixing. Sometimes she has had to puzzle out what might be wrong, asking another expert to describe what she heard as he played.
Her ear provided external judgment. “She is very tough, and that’s what I like about it,” Perlman says. He doesn’t always trust his response when he listens to recordings of his performances. He might think something sounds awful, and then realize he was mistaken: “There is a variation in the ability to listen, as well, I’ve found.” He didn’t know if other instrumentalists relied on coaching, but he suspected that many find help like he did. Vocalists, he pointed out, employ voice coaches throughout their careers.
The professional singers I spoke to describe their coaches in nearly identical terms. “We refer to them as our ‘outside ears,’ ” the great soprano Renée Fleming told me. “The voice is so mysterious and fragile. It’s mostly involuntary muscles that fuel the instrument. What we hear as we are singing is not what the audience hears.” When she’s preparing for a concert, she practices with her vocal coach for ninety minutes or so several times a week. “Our voices are very limited in the amount of time we can use them,” she explains. After they’ve put in the hours to attain professional status, she said, singers have about twenty or thirty years to achieve something near their best, and then to sustain that level. For Fleming, “outside ears” have been invaluable at every point.
So outside ears, and eyes, are important for concert-calibre musicians and Olympic-level athletes. What about regular professionals, who just want to do what they do as well as they can? I talked to Jim Knight about this. He is the director of the Kansas Coaching Project, at the University of Kansas. He teaches coaching—for schoolteachers. For decades, research has confirmed that the big factor in determining how much students learn is not class size or the extent of standardized testing but the quality of their teachers. Policymakers have pushed mostly carrot-and-stick remedies: firing underperforming teachers, giving merit pay to high performers, penalizing schools with poor student test scores. People like Jim Knight think we should push coaching.
California researchers in the early nineteen-eighties conducted ...
