A Maximalist Career

A Modest Surgeon with Grandiose Dreams

Atal Gawande is one of my professional role models. His resume is, to put it mildly, impressive. He's a cancer surgeon at Brigham Women's Hospital, professor at the Harvard T.H. Chan School of Public Health and the Samuel O. Their Professor of Surgery at Harvard Medical School, Staff Writer at the New Yorker, author of several New York Times best-selling books, founding executive director of a joint centre for health systems innovations, and the CEO of the new healthcare venture formed by Amazon, Berkshire Hathaway and JP Morgan Chase. He's also a husband and father of three children.

Out of all his accomplishments, I admire his desire to push the boundaries of his career. It's one thing to be a skilled surgeon, it's quite another to push oneself to write about his curiosities: Why does healthcare cost so much? Why do people itch?

It seems that no matter the project, he achieves excellence. What’s his secret?

After some ol’ fashion Internet sleuthing, I managed to find the answer: Gawande believes in coaches.

In an article written over eight years ago, Gawande shared how he noticed the complication rate in his surgeries had begun to plateau. He had been operating for more than a decade and he was no longer developing his skills.

He looked to the sports and entertainment industries for guidance. "So outside ears, and eyes, are important for concert-caliber musicians and Olympic-level athletes," he wrote, "What about regular professionals, who just want to do what they do as well as they can?"

Gawande approached Robert Osteen, a retired general surgeon whom he respected and had trained under during his residency, whether he would indulge him in the task. Osteen agreed.

He wrote about the first operation that Osteen observed: "The case went beautifully... Osteen had rarely done this operation when he was practicing, and I wondered whether he would find anything useful to tell me."

To Gawande's surprise, however, Osteen had an entire list of observations from how he positioned his elbows to how he draped the patient. Gawande considered the feedback:

That one twenty-minute discussion gave me more to consider and work on than I'd had in the past five years. It had been strange and more than a little awkward having to explain to the surgical team why Osteen was spending the morning with us. "He's here to coach me," I'd said. Yet the stranger thing, it occurred to me, was that no senior colleague had come to observe me in the eight years since I'd established my surgical practice. Like most work, medical practice is largely unseen by anyone who might raise one's sights. I'd had no outside ears and eyes.

Gawande also took to recording his surgeries and showing the videos to Osteen for feedback. Over time, Osteen noted incremental improvements:

Since I have taken on a coach, my complication rate has gone down. It's too soon to know for sure whether that's not random, but it seems real. I know that I'm learning again. I can't say that every surgeon needs a coach to do his or her best work, but I've discovered that I do.


Deliberate Practice

Gawande discovered the magic of deliberate practice.

A term labeled by Dr. K. Anders Ericsson, a psychology professor who has devoted his entire career studying elite performers, and the focus of his book, "Peak: Secrets from the New Science of Expertise."

To summarize Ericsson’s work in a single sentence: The development of skills is not a result of time spent on a specific set of actions but more so time spent on the right set of actions.

It’s not about ordinary practice but deliberate practice.

Ericsson's research may seem controversial, especially to professions who prize seniority. For instance, he concludes that doctors early in their careers perform better than doctors who’ve been working for decades. This is due to doctors working alone, don’t change their methods and have no coaches or peers to provide feedback. Though doctors continue to practice their skills, they don’t engage in deliberate practice. Ericsson argues that doctors who improved in all three areas made better diagnoses.

It is hard to believe that lawyers remain immune to the benefits of deliberate practice.

As a workplace lawyer, I appear before specialized adjudicative tribunals and boards. Hearings require an intense amount of focus. Not only are you concerned about questioning your client and various witnesses, but the level of uncertainty from unanticipated issues that may arise over the course of the hearing is huge. I’m not being paid to check my e-mails or browse the latest case law. I’m there to advocate.

In the midst of a hearing, there’s no doubt I can benefit from an extra set of eyes, especially someone who can sit in the back of a room and record when a witness looks agitated during a particular line of questioning or when I speak too fast during my closing submissions.

But for lawyers, this requires an enormous dose of humility. Not an easy trait in a profession that prides itself as upholders of the justice system. Society wants to know that lawyers are competent in their craft and not still learning after a decade of practicing. But it’s important if we want to continue advancing our skills.

It then is no surprise that Gawande, despite all of his success as a surgeon, writer, and researcher, is profoundly humble. In a tribute to Oliver Sacks upon his passing, Gawande reminisced on the impact the late surgeon left on him:

Up to that point, I'd regarded writing as a lucky sideline to my surgical career and hardly felt like someone who deserved to call himself a writer. But, because Sacks seemed to be holding my work to a higher standard, I realized that I needed to as well.

Weekly Consumables

Here’s what I’m enjoying this week:

See you next Tuesday.