How does a person become great at doing something difficult? (Brain surgery)

Among many other virtues, Do No Harm: Stories of Life, Death, and Brain Surgery (Marsh), contains some stuff about how a human can be trained to become great at a difficult task.

Henry Marsh describes his youth in a comparatively uncompetitive world:

Until the age of twenty-one I had followed the path that seemed clearly laid out for me by my family and education. It was a time when people from my background could simply assume that a job was waiting for them – the only question was to decide what you wanted to do. I had received a private and privileged English education in a famous school, with many years devoted to Latin and Greek, and then to English and History. I took two years off on leaving school, and after several months editing medieval customs documents in the Public Record Office (a job organized by my father through his many connections), spent a year as a volunteer teaching English literature in a remote corner of West Africa. I then went up to Oxford to read Politics, Philosophy and Economics.

I was destined, I suppose, for an academic or administrative career of some kind. During all these years I had received virtually no scientific education.

I was fortunate that my college at Oxford allowed me to come back after my year away to complete my degree and I was later accepted to study medicine at the only medical school in London which took students without any scientific qualifications. Having been rejected by all the other London Medical Schools since I had neither O-levels nor A-levels in science I had telephoned the Royal Free Medical School. They asked me to come for an interview next day. The interview was with an elderly, pipe-smoking Scot, the Medical School Registrar, in a small and cramped office. He was to retire a few weeks later and perhaps he let me in to the Medical School as a kind of joke, or celebration, or perhaps his mind was elsewhere. He asked me if I enjoyed fly-fishing. I replied that I did not. He said that it was best to see medicine as a form of craft, neither art nor science – an opinion with which I came to agree in later years. The interview took five minutes and he offered me a place in the Medical School starting three weeks later. Selection for medical schools has become a rather more rigorous process since then. I believe the Medical School at the huge London hospital where I now work uses role-playing with actors, along with many other procedures, to select the doctors of the future. The nervous candidates must show their ability to break bad news by telling an actor that their cat has just been run over by a car. Failure to take the scenario seriously, I am told, results in immediate rejection. Whether this is any better than the process I went through remains, I believe, unproven. Apparently the actors help select the successful candidates.

Marsh is a big believer in long hours for novice doctors, but that’s no longer how people are trained:

I wanted to be a surgeon – at least I thought I did – so I managed to get a job on a surgical ‘firm’, as it was called, in my teaching hospital. The firm consisted of a consultant, a senior registrar and a junior registrar and the houseman. I worked ‘1 in 2’, which meant I did a normal working day five days a week, but also was on call every other night and every other weekend, so I was in the hospital for about 120 hours a week.

It was at the time when the government was starting to reduce the long working hours of junior hospital doctors. The doctors were tired and overworked, it was said, and patients’ lives were being put at risk. The junior doctors, however, rather than becoming ever more safe and efficient now that they slept longer at night, had instead become increasingly disgruntled and unreliable. It seemed to me that this had happened because they were now working in shifts and had lost the sense of importance and belonging that came with working the long hours of the past. I hoped that by meeting every morning to discuss the latest admissions, to train the juniors with constant teaching as well as to plan the patients’ treatment, we might manage to recreate some of the lost regimental spirit.

‘If they are to be compliant with the European Working Time Directive your registrars can no longer be resident on-call. The on-call room will be taken away. We have examined their diary cards – they are working far too much at the moment. They must have eight hours sleep every night, six of it guaranteed uninterrupted. This can only be achieved if they work in shifts like the SHOs.’ My colleagues stirred uncomfortably in their seats and grumbled. ‘Shifts have been tried elsewhere and are universally unpopular,’ one of them said. ‘It destroys any continuity of care. The doctors will be changing over two or three times every day. The juniors on at night will rarely know any of the patients, nor will the patients know them. Everybody says it’s dangerous. The shorter hours will also mean that they will have much less clinical experience and that’s dangerous also. Even the President of the Royal College of Surgeons has come out against shifts.

‘We have to comply with the law,’ she said

How good can a person get with this kind of training plus a career’s worth of experience?

Early the next morning I lay in bed thinking about the young woman I had operated on the previous week. She had had a tumour in her spinal cord, between the sixth and seventh cervical vertebrae, and – although I do not know why, since the operation had seemed to proceed uneventfully – she awoke from the operation paralysed down the right side of her body. I had probably tried to take out too much of the tumour.

More: Read Do No Harm: Stories of Life, Death, and Brain Surgery