There are occasions when one has a surgical trainee who is observed to have “great hands” and is felt destined to have the tools to be a “great surgeon.” Yet, is exceptional dexterity all that is needed?
Surgery has its roots as far back as ancient Egypt, and very likely at every epoch there have been individuals who might well have exhibited all the attributes to fulfill the moniker of “a great surgeon.” With the rapid advances in technology and with surgical training undergoing major transformation, it might be useful to more clearly define what it ultimately takes to be considered the top of the field.
Atul Gawande, MD, in his article entitled “Creating the educated surgeon in the 21st century”1 noted that it has long been recognized that good surgery requires technical skill, safe judgment, and dedication. Adding to these criteria would be communication skills, decision-making skills, and empathy for the patient. Yet, those individuals who prove to be “great surgeons” must have something more to stand above their well-trained peers.
Perhaps we can find some answers from the insights of Malcolm Gladwell. Writing in an article in the New Yorker entitled “The Physical Genius,” he compared the accomplishments of 3 luminaries in their very separate fields—hockey star Wayne Gretsky, Yo Yo Ma, and San Francisco neurosurgeon Charlie Wilson.2 He surmised that each had the ability to translate thought into action, which he termed “physical genius.” Gladwell suggested that outstanding surgeons seem to “always know where they are going” and, importantly, this may take years to develop and may not be able to be taught.
When further analyzing the “greatness” of these 3 individuals in very different professions, he identified that success was dependent upon 3 important factors. The first involved individual ability—although long thought to be the most important determinant, it is not simply hand-eye coordination but rather “ a practical-minded obsession with the possibility and consequences of failure.” He further implied this may not be easy to obtain.
The second fundamental criterion is the repetitive performance of specific tasks, which could enhance the ability, when faced with complex procedures, to view the situation in component parts. This requires not only analysis of mistakes and poor outcomes but also repeated practice to master the techniques. Dr Tsu-Min Tsai, my mentor during my hand surgery fellowship in Louisville, is famous for recounting how he developed his proficiency in microsurgical techniques only after reanastomosing 400 amputated rabbit ears.
The third and perhaps most interesting component is the concept of “physical greatness” present in the very highest level of performers. Gladwell defines this as a certain “vision” to be able to handle novel situations. The development of such vision requires not just experience but also a certain orientation of one’s mind to be able to see the entire operative field as a whole.
Fred Hapgood in his book “Up the Infinite Corridor” recognized something very similar in elite engineers, which he described as a sense for the “fitness of things.”3 He suggests this to be a gift that could not be taught, and those who had it, like great surgeons, had it in their soul.
We live in challenging times as surgical volumes are decreasing, trainees have time restrictions, and the opportunity to nurture the qualities espoused by Gladwell seem to be increasingly difficult. Yet, there will certainly be forthcoming individuals who will have that “physical greatness” and continue to further the surgical field.
In the 6th-century BC, Sushruta the father of Indian surgery offered these words:
Surgery has the superior advantage of producing instantaneous effects by means of surgical instruments and appliances. Hence, it is the highest in value of all the medical tantras.4
It is eternal and a source of infinite piety, imports fame and opens the gates of heaven and its votaries. It prolongs the duration of human existence on earth and helps men in successfully fulfilling their mission and earning a decent competence in life.
1. Gawande AA.Creating the educated surgeon in the 21st century.Am J Surg.2001;181:551–556.
2. Gladwell M.The Physical Genius.1999.New York:The New Yorker.
3. Hapgood F.Up the Infinite Corridor.1993.Boston, MA:Addison-Wesley Co.
4. Sushruta Samhita. English translation by Kavitraj Kunja lai Bhishagratna, Chapter 16, Calcutta, 1907, 152–154.