What is it that sets some surgeons apart from others? What makes the difference between a skilled professional and a true master?

 

"Not every person with an MD (medical doctor) is the same", advises Drew Bednar, Clinical Professor of Orthopedic Surgery at McMaster University, Hamilton, Canada, in his website for educating spine surgery patients.  Basic factors may have an impact on a surgeon's success rate, such as where the surgeon was trained, what certifications and licenses they hold, and the number of times the surgeon has actually performed spine surgeries.

 

However, these factors represent only the tip of the iceberg. Like artists, surgeons learn their trade through sheer hard work and dedication. Only after gaining the basic set of skills and knowledge can surgeons adapt their procedures to the individual needs of the patient on a case-by-case basis, and allow themselves "artistic license". Expert surgeons have often been compared to artists, because their success is not just due to medical knowledge and experience, but also to a combination of talent, manual dexterity and instinct that is hard to quantify.

 

Drawing the line

On the other hand, a recent debate has emerged about whether surgeons should even be compared to artists at all. Surgery, after all, is an integral part of the practice of medicine, and medicine is evidence-based and factual. The treatment of patients, the conduct of clinical trials and the testing of new techniques or drugs are activities that value objectivity, rationality and factual knowledge.

 

In his blog, Richard Baxter, MD of the Plastic Surgery Clinic in Seattle, Washington, USA, discusses how art and science intersect in his daily practice.  "I have always felt that my formal training in art, coupled with a belief in the scientific method, gives me a unique aptitude in plastic surgery," he reveals.

 

According to Baxter, surgery is more than the sum of its parts. "[…]Surgeons are not merely technicians, and our practices are more than a menu list of standardized operations. We are creative by nature, and patients expect customized approaches guided by a sense of the subtleties that define natural beauty," he states.

 

The challenge arises when there is an absence of solid data to guide clinical practice, as is the case with many of the latest surgery techniques. "We know a lot about many small aspects of spine function, from biomechanics to anatomy to biochemistry to whatever, but we don’t have a good comprehensive understanding or “model” of how the whole spine as a unit works at all yet," states Professor Bednar. "Effectively we know a lot about the trees but we don’t understand the forest."

 

"In plastic surgery, the problem is especially troublesome, with everyone touting the next best thing before it can be evaluated for effectiveness," explains Baxter. "But the artists among the ranks point out that beauty cannot be readily defined by science, and without a sense of proportion and aesthetics, technical expertise and rote adherence to protocol are inadequate."

 

For Christopher Hyer of the Orthopedic Foot and Ankle Center in Westerville, Ohio, USA, observing different solutions to the same problem is part of the magic. One surgeon may get beautiful results with this while another may get the same outcome with another method. Is one better than the other? Not necessarily, different techniques can produce the same outcome."

 

Going with the flow

In his article entitled "Zen and the Art of Surgery: How to Make Johnny a Surgeon",  David Mahvi muses on what it takes to train and produce a competent surgeon. "To become an expert requires 10,000 hours of deliberate practice over an extended period of time. It does not matter what task you pick—sports, music, chess," says Mahvi.

 

According to Mahvi, specialized training is key for producing true experts in a particular branch of surgery. He takes this concept one step further, and introduces the notion of deliberate practice. "It has three components—it must be beyond your current level of performance, there must be feedback, and you must be doing it not because you are required, but for its own reward." Mahvi explains. Once surgeons have gained a solid level of competence, they must narrow their sights and focus on developing their true expertise.

 

What is the true goal of all this rigorous training? "The real value of surgical education is the freedom that comes with self-awareness and the flow that happens during a great surgical procedure," states Mahvi. "This means focusing completely and totally on the patient."

 

As in all professions, a true master is the one who can achieve the process of flow. Mihaly Csikszentmihalyi, psychologist and author of the original work entitled "Flow: The Psychology of Optimal Experience", says that flow is a state of complete absorption with the activity and situation at hand. According to Csikszentmihalyi, nine component states are needed for achieving flow: “challenge-skill balance, merging of action and awareness, immediate and unambiguous feedback, concentration on the task at hand, paradox of control, transformation of time, loss of self-consciousness, and autotelic experience.”

 

10’000 hours of practice

David Mahvi, however, reminds us that there is no such thing as a free lunch. "It takes 10,000 hours of deliberate practice over 10 years to get there," he cautions.

 

So how does this apply to surgeons, who have already sacrificed years of their lives in training? New surgeons typically do not have the experience that allows them to be comfortable enough, let alone reach Csikszentmihalyi's state of "autotelic experience". Besides that, there are many surgeons out there who are excellent at what they do despite never having attained flow.

 

One important point, according to Mahvi, is to remember why you chose this profession in the first place. "Commit yourself to becoming an expert in something," he suggests. "Prioritize your time, and do what makes you happy."

 

Another key to success is a solid foundation of knowledge. "Where I think we can go astray is when everything looks like a nail and all we bring to the table is a hammer," says Christopher Hyer. "In a given year, how many different types of procedures might you do for problem X? I think you will see the art in action when you hear the answer."1

 

Learning from the masters

One important aspect of medicine is that every surgeon depends upon the work of his or her predecessors. Ugo Tesler of the Department of Cardiac Surgery at the Clinica San Gaudenzio, Novarra, Italy, compares and contrasts art versus surgery in his article entitled "The history of art versus the art of surgery".

 

"Scientists are not dependent on the ideas of a single person, but on the combined wisdom of thousands," states Tesler. "This combined wisdom, collectively accumulated and continuously enriched and refined over the years, is the intellectual heritage that, through the actions of its members in their roles as mentors, is handed down to new generations."

 

In his inaugural lecture presented at the 23rd annual meeting of the European Association for Cardio-thoracic Surgery, Erino Rendina expands on the profound influence of the mentor in shaping a surgeon's career.  "The figure of the mentor is central; he or she is the driving force of learning," says Rendina. "Not only his or her technical skills, judgment and wisdom, but also his or her personality and human qualities influence the pupil in depth and forever."

 

As for artists, those surgeons who are lucky enough to train with a true master gain not only the technical skills of the trade, but absorb the true beauty of their profession. "Learning in surgery lasts a lifetime," states Rendina.

 

Bringing it all together

Ultimately, surgery is something that embraces many disciplines. A master surgeon operates from a solid scientific base, but is guided by skill, experience and judgment in an endeavour that is part craft and part performance. This concept is explored by Roger Kneebone, professor of Surgical Education at the Department of Surgery and Cancer, Imperial College London. In an open lecture at the Faculty of Medicine at London's Imperial College, Kneebone argues that integrating the worlds of science, technology, art, humanities and performance is central to producing surgeons with skill and compassion.