From Interns to Experts: Tips for Training and Beyond

It is challenging to picture a path toward expertise when receiving an evaluation with criticisms such as "read more" or "needs to continue to practice." These vague phrases are unfortunately common, but pale in comparison to even more damaging comments labeling learners as "not cut out for the field," "not at the level of peers," or even "above average." These painfully powerful statements may reflect a conflated notion of the evaluator's ability to know who should be a physician and what the future holds, but more importantly demonstrate how poorly we understand and teach others how to learn and improve. Harmful feedback like this does not help trainees, or even experts, conceptualize the steps to take to meet a goal on the path toward mastery of surgery.

Fortunately, the path towards expertise in complex cognitive and technical fields has been robustly studied in the science of psychology, and there are simple principles from psychology, which when applied by both learner and expert-coach, can accelerate learning and can be applied throughout one's lifetime. One leader in this field is the late Anders Ericsson, PhD, who spent a lifetime of academic and practical work exploring the psychology of expertise and human performance. Dr. Ericsson debunks the prejudicial idea of "natural talent" in his 2016 book, Peak: Secrets from the New Science of Expertise.¹ He points instead towards the foundational components of expertise: exposure, focus, and deliberate practice. Though his work on expertise sparked the 10,000 hours rule,² Peak was Ericsson's platform to refocus attention from oversimplification of mastery to a more nuanced model illustrated by examples from athletics and music, but also medicine and surgery. He insisted that mastery was not about the number of hours, but is rather in how those hours are spent. What may take one person 10,000 hours to master may take another person harnessing the key principles of deliberate practice only 7,000 hours.

Dr. Ericsson had agreed to write a piece for the American College of Surgeons, to be published here in Resources in Surgical Education. We connected with him through mutual acquaintances and created an abbreviated scaffold of Peak, designing it to be a condensed guide to Dr. Ericsson's work that might more readily reach busy practitioners at all levels of training. We reviewed our notes with him in June 2020. Sadly, Dr. Ericsson died unexpectedly just two days later.

What follows are eight key points and recommendations for how to apply them in practice from Peak—points that can lead to an accelerated learning curve in many fields if followed (see table below). These points are especially relevant in the era of competency-based education, where progression from novice to expert is measured not in time spent, but in practice and principles achieved and demonstrated. Given his personal input to this outline, we are confident that Dr. Ericsson would have wanted all lifelong learners in surgery, from interns to experts, to read these.

The allure of natural talent is undeniable. However, this paradigm implies preset limits to mastery and perpetuates prejudicial narratives about who becomes an expert. There is no evidence for the superiority of natural talent over the persistent and focused practice. The real of mastery lies in recognizing our universal adaptability and harnessing it through intentional actions.

Application

Practice with universal potential in mind. In a teaching role, do not use labels. Avoid classifying anyone as a "natural" (which can paradoxically discourage hard work) or as a "lost cause" (which only has negative impact). For the learner, confront attempts to be labeled by others. Instead, both parties should focus on concrete examples of strengths and weaknesses tailoring both feedback and practice to the learner's observable skills and location on the continuum from novice to master.

Deliberate practice is both purposeful and informed. Most practice is purposeful as long as a particular skill or concept is identified. More difficult to attain is informed practice. Examples of uninformed practice are the medical student tying hundreds of knots with poor technique or the practicing surgeon performing an operation the same way every time without following up on a patient's outcome. Although there is a purpose identified, there is no refinement of technique with each iteration.

Application

Check that your practice is:

• Goal-oriented and sequential: Define concrete levels of achievement (for example, set a needle in a needle driver via a laparoscopic simulator box consistently before learning to suture or tie laparoscopically).
• Methodical and finite: Use short spurts of additive, regular practice. Do not leave your planned practice for your next rotation or next big case to the week before. Identify a relevant skill or technique and incorporate that practice into a shorter and regular routine.
• Active: Devote your full attention and focus to practice (i.e., minimize distractions).
• Responsive: Seek feedback from a coach periodically between bits of independent practice. For example, ask someone to watch you attempt a specific skill and propose the next steps every few weeks. The expert will see things you don't and refining technique will lead to more productive practice during the next session. For those who are advanced in training of career, ask for granular feedback from a partner or coach.

Along this path from novice to master, you will realize elements of your day that previously were difficult are no longer challenging. The inherent comfort will be tempting but contentment leads away from deliberate practice and puts you at risk of falling into naïve practice—this applies to both novice and experienced practitioners.

Application

Use the feeling of comfort as a call to action. Seek discomfort and refuse to live in a world of "good enough." Search for new opportunities (under supervision) that are outside of your comfort zone. Always look for challenging opportunities; take an extra call on a difficult service; scrub into an operation; or lead a lecture or discussion.

A poor practice action plan is one that is built upon didactics alone. There can be diminishing returns on passive listening to lectures, which offer little feedback and few chances to try something new or make mistakes. Shifting your framework to active practice is key. When you find yourself complacent, instead move to action.

Application

Take any opportunity to make a passive situation active. Get your hands dirty with direct patient care; whether it's a new patient in the emergency department or chance to double scrub in an operating room, be the first to volunteer for everything.

Top Gun pilots train in hundreds of simulated scenarios and partially simulated scenarios with direct feedback on actions and outcomes. The more opportunities you have to practice a procedure under observation with direct feedback from an expert attending, the better your technical and cognitive skills will become.

Application

Cherish any time with expert supervision. Under expert guidance, seek out difficult operations, procedures, and, even, challenging patients. See as many variations of scenarios as you can, then ask for and incorporate direct feedback. Be deliberate in communicating where your deficiencies are. Then diligently follow up on outcomes to reflect on your care and make changes where necessary.

As a surgery resident, and later as an attending, you will face seemingly insurmountable challenges. While moments of anxiety, discomfort, and confusion are signals that your training or practice areas require more deliberate attention, they are not signals to quit.

Application

When you run up against a barrier, seek a mentor or senior expert for feedback. It is very likely they have encountered the same barrier previously and may be able to coach you through it by proposing a different approach.

Mental models are key tools for situating deliberate practice in the real world; they help one place new information quickly and recognize patterns of practice. A mental model of a disease process or operation might look symbolically like a map of a new territory. This map is adjusted with new trails and paths with every new patient or operation you encounter. Novice learners' mental models start as basic frameworks but grow into complex labyrinths.

Describing your thinking as a trainee allows your supervising expert to assess your understanding of the case in real time and help you adjust your mental model with focused practice.

Describing your thinking as an attending guides trainees through your mental model and helps them fill in gaps in their own map.

Application

For both attendings and trainees, communicate your understanding and decision making in diagnoses, presentations, procedures, operations, and images. For trainees, do not be afraid to be wrong—experts can help you fill in the holes only if they know where those holes are or where their perception deviates from yours.

All lifelong learners in surgery feel a constant tension between education and service. When completing a task or a procedure that you deem service, include all the elements of deliberate practice—be focused, be methodical, be active, and seek feedback no matter how menial the task. Inquire about how experts around you make decisions and ask them for feedback about your own reasoning. When you outreach your understanding, seek that uncomfortable feeling, and expand the scope of your mental model for that problem.

Application

Rather than reflexively and negatively labeling something as service, change your outlook and incorporate deliberate practice into the perceived service. When you are doing tasks you feel you have already mastered, look for the variation and learn from the variation. In this way, the medical record, the bedside, and the operating room are most efficiently used as the practical classrooms.

Dr. Ericsson was steadfast in his belief that deliberate practice will revolutionize our understanding of human potential. He envisioned a world where there are not only far more experts but far more experts in a greater variety of fields. The key to this revolution is recognizing the sham of innate talent and instead validating paths to expertise built upon years of practice with an adaptable human body and brain. Dr. Ericsson knew that this realization was not enough; widespread and equitable paths to expertise would require both spreading the word about deliberate practice and providing people with tools to harness adaptability and control their potential.

So how do we harness the potential of deliberate practice in the surgical context? These points from Dr. Ericsson's work are just the beginning. They are part of the recognition phase, but the next steps rely on action—action on behalf of your current and future patients.

1. Ericsson A, Pool R. Peak: Secrets from the new science of expertise. Houghton Mifflin Harcourt, 2016.
2. Gladwell, M. Outliers: The story of success. Little, Brown and Co, 2008.

Kyle E. Cassling, MD, MEd, is a general surgery resident in the department of surgery, Vanderbilt University Medical Center, Nashville, TN.

Kyla P. Terhune, MD, MBA, FACS, is vice president for educational affairs, associate dean for graduate medical education, and associate professor of surgery and anesthesiology, department of surgery, Vanderbilt University Medical Center, Nashville, TN.