Here is a brief excerpt from an article written by Atul Gawande for The New Yorker magazine. To read the complete article, check out the wealth of resources, and obtain subscription information, please click here.
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No matter how well trained people are, few can sustain their best performance on their own. That’s where coaching comes in.
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.
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To read the complete article, please click here.
Atul Gawande is the author of The Checklist Manifesto, Better, and Complications. He is also a MacArthur Fellow, a general surgeon at the Brigham and Women’s Hospital in Boston, a staff writer for The New Yorker, and an assistant professor at Harvard Medical School and the Harvard School of Public Health. He lives with his wife and three children in Newton, Massachusetts.