The Paradox of Balance : Techniques in Hand & Upper Extremity Surgery

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The Paradox of Balance

Shin, Alexander Y. MD

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Techniques in Hand & Upper Extremity Surgery 26(1):p 1, March 2022. | DOI: 10.1097/BTH.0000000000000378
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“I’m looking for a program that will enable me to have balance in my life” —Applicant for Resident Training Program

The answer to “what are you looking for in a resident training program?” stopped me right in my tracks during a recent zoom interview and provided me fodder to ponder the implications of balance in one’s life during a career as a surgeon.

Can someone striving for a future career that requires intense study, years of hands-on surgical training, sleepless nights of call, continued postgraduate medical education, with evaluation and revaluation of outcomes, truly be balanced? Expanding this thought to other professions quickly elucidated the paradox of balance.

The world of sports, amateur or professional, provides numerous examples of the paradox of balance. Every accomplished athlete will readily admit that thousands of hours of practice are necessary to develop the skills to excel and that while natural talent might exist, it requires purposeful practice and the sacrifice of time to optimize performance. In upper Midwest where Hockey is king, many teenagers will wake up at 5:30 am to get “ice time” to practice. At the same time, swimmers will sacrifice early hours and hours after school to get “pool time” to perfect their skills. At the professional level, all athletes have sacrificed time, effort, social interactions, or relationships to hone their skills and craft to achieve their current status. Ericsson et al evaluated the role of deliberate practice in the acquisition of expert performance and noted that “characteristics once believed to reflect innate talent were actually the result of intense practice extended for a minimum of 10 years.1” This research has been the basis of the 10,000 hour rule popularized by Malcom Gladwell in this book “Outliers.2” It makes one cogitate if greatness and balance can co-exist?

What was this the “balance” that the interviewee was seeking? In Physics balance occurs when 2 individual forces of equal magnitude and opposite directions act upon an object resulting in a state of equilibrium. An object remains in its equilibrium state, unchanged, until an inequality in the magnitude or direction of the forces occurs. Equilibrium, however, is rarely observed in nature and the world around us, where there are multiple forces in a variety of directions acting in a continual state of flux. When balance does occur, it is fleeting and rarely, if ever, long-lasting.

The forces disrupting the balanced state can be external or internal. External forces are situational (promotions, advancements, competitions) or from individuals (parents, teachers, friends, coaches, mentors) while internal forces are the inner drive or grit for success or improvement. Without these unbalancing forces, our skills as a surgeon will not improve or advance. There are constant unbalancing forces: failed diagnoses, poor surgical decision making or execution, complications, etc. Trying to obtain equilibrium when these unbalancing forces hit us drives us to read, learn, and practice—and the entire cycle starts again, with the goal that we improve, get better and do better for our patients.

The paradox of balance is powerful to analyze and understand. Anyone (athlete, surgeon, business person, skilled worker, artist, etc.) who has attained greatness and success, by definition, has never been balanced nor intentionally sought balance—as they have sacrificed more than others will ever know or care to know to become who they are. Balance equals mediocrity. In the surgical world, imbalance drives innovation, improvement in patient care, and excellence. I became a surgeon and strived to be the best surgeon possible. That goal came with a price: being unbalanced. I am certain I would not be the surgeon I am today if my goal was to seek balance. It makes me wonder what that resident applicant’s career would be like in 20 years or if he/she really understands the implication of the balance paradox.


1. Ericsson KA, Krampe RT, Tesch-Römer C. The role of deliberate practice in the acquisition of expert performance. Psychologic Rev. 1993;100:363–406.
2. Gladwell M. 1963-author. Outliers: The Story of Success. New York, NY: Little, Brown and Company; 2008.
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