10,000 Hours or Ten Years to Expert Performance in Surgery

Martin McKneally

In the Chairman's column, Richard Reznick contrasts the extensive time requirement for development of expertise recounted by Malcolm Gladwell in his best-selling book Outliers with the current restrictions on the hours of training prescribed for surgical residents in Europe and North America. In his provocative and articulate style, Gladwell explicates the remarkable research of K. Anders Ericsson, A.C. Lehmann and their colleagues at the Max Planck Institute for Human Development in Berlin (1). These authors studied musicians at the elite Berlin School of Music, as well as typists, professional athletes, chess champions and other experts. 10,000 hours of deliberate practice was critical for taking musicians to a level of expertise that enabled them to play in a professional orchestra on the concert stage, or for athletes to compete at a professional level.

Deliberate practice was defined as skillful deconstruction, critical analysis, and reflective repetitive practice with expert feedback from coaches or from disciplined self-study.

Professionals engage in "deliberate practice, perfecting components of performance analytically with multiple repetitions and improvements". Tiger Woods works on perfecting defined components of his golf swing. Michael Phelps tests and develops minor changes in his strokes or kicks to improve his performance in the pool. Simply hitting balls or swimming laps is not deliberate practice. Coaching and feedback are an important component; they should be consistent and based on expert technical knowledge.

The analogy to surgical training is tempting to draw. The development of fast twitch fibres and recruiting of muscle memory to choreograph digital and instrumental movements fits well. All analogies limp, and the limp occurs at the point where the similarity breaks down. Surgeons in training don't get much deliberate practice, though they get a lot of surgical work. Ericsson: "Let us briefly illustrate the differences between work and deliberate practice. During a 3-hr baseball game, a batter may get 5-15 pitches [perhaps one or two relevant to a particular weakness], whereas during optimal practice of the same duration, a batter working with a dedicated pitcher has several hundred batting opportunities, where his weakness can be systematically explored." The potential contribution of the simulation lab springs to mind.

In a thoughtful recent editorial in the Canadian Medical Association Journal, British Columbia neurosurgeon David A. Omahen dissects the analogy further (2). He calculates that the 10,000 hour mark is attained in neurosurgery residency in about 6.9 years. He draws attention to the apparent coincidence that most neurosurgery residencies are six years long, with many residents electing to take one extra year of fellowship training. He questions how much of the 10,000 hour experience qualifies as deliberate practice. "The time spent by a resident watching an operation from the sidelines, or admitting the fifth 'weak and dizzy' patient at 4am probably doesn't fall into the category of deliberate practice!" Omahen also underlines Ericsson's finding that high level violinists took naps during the day and got a statistically significant greater amount of sleep than those who wound up as violin teachers rather than concert performers. He closes on an optimistic note - that effective teachers, perhaps those with ten years or 10,000 hours of deliberate practice at teaching, can have a powerful and lifelong impact on learners "by placing information in a meaningful context, creating situations that facilitate deliberate practice and providing immediate valid feedback".

In defense of the value of residents' work, we can reflect on Gladwell's interesting observation that prodigies with great technical skill in music often do not develop into mature concert musicians unless they develop the social and other less technical components of mature performance. This may be used as part of the justification for the diverse tasks residents perform outside the operating room. Many of these experiences teach surgeons needed social skills and help them develop mature judgement as their decisions are reviewed by senior colleagues, experienced nurses and thoughtful patients.

We are fortunate to have analytic educational scholars in our department like Glenn Regehr, Richard Reznick and their colleagues who continue and extend the analytic work of Ericsson. Studying timing, errors, and instrument movement in the laboratory, they have demonstrated that improvements developed during deliberate practice significantly transfer into effective surgical treatment of living patients (3, 4).

Martin McKneally

(1) Ericsson KA, Lehmann AC. Expert and exceptional performance: evidence of maximal adaptation to task constraints. Annu Rev Psychol 1996;47:273-305.

(2) Omahen DA. The 10,000-hour rule and residency training. CMAJ June 9, 2009;180(12):1272.

(3) Mylopolous R, Regehr G. Cognitive metaphors of expertise and knowledge: prospects and limitations for medical education. Med Educ 2007;41:1159-65.

(4) Park J, MacRae H, Musselman LJ, Rossos P, Hamstra SJ, Wolam S, Reznick RK. Randomised controlled trial of virtual reality simulator training: transfer to live patients. Am J Surg 2007;194(2):205-11.