Personal Best - Atul Gawande

8/3/2019 Personal Best - Atul Gawande

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cations moved steadily lower and lower.And then, a couple of years ago, theydidn't. It started to seem that the onlydi-rection things could go from here was thewrong one.

Maybe this iswhat happens when youturn forty-five. Surgery is, at least, a rela-tively late-peaking career. It's not likemathematics or baseball or pop music,where your best work isoften behind youby the time you're thirty. Jobs that involvethe complexities of people or nature seemto take the longest to master: the averageage at which S. &P. 500 chief executiveofficers are hired is fifty-two, and the ageof maximum productivity for geologists,one study estimated, is around fifty-four.Surgeons apparently fall somewherebetween the extremes, requiring bothphysical stamina and the judgment thatcomes with experience. Apparently, I'darrived at that middle point.

Itwouldn't have been the first time I'dhit a plateau. I grew up in Ohio, andwhen I was in high school I hoped to be-come a serious tennis player. But Ipeaked at seventeen. That was the yearthat Danny T revas and I climbed to thetop tier for doubles in the Ohio Valley. Iqualified to play singles in a couple of na-tional tournaments, only to be smotheredin the first round both times. The kids atthat level were playing a different gamethan I was. At Stanford, where I went tocollege, the tennis team ranked No.1 inthe nation, and I had no chance ofbeingpicked. That meant spending the pasttwenty-five years trying to slow thesteady decline of my game.

I still love getting out on the court ona warm surnmer day, swinging a racquetstrung to fifty-six pounds of tension at atwo-ounce felt-covered sphere, and try-ing for those increasingly elusive mo-ments when my racquet feels like an ex-tension of my arm, and my legs areputting me exactly where the ball is goingto be. But I came to accept that I'd neverbe remotely as good as I was when I was

Ivebeen a surgeon for eight years. Forthe past couple of them, my perfor-mance in the operating room has reacheda plateau. I'd like to think it's a goodthing-I've arrived at my professionalpeak. But mainly it seems as ifI've juststopped getting better.

During the first two or three years inpractice, your skills seem to improve al-most daily. It's not about hand-eye coor-dination-you have that down halfwaythrough your residency. As one of myprofessors once explained, doing surgeryis no more physically difficult than writ-ing in cursive. Surgical mastery is aboutfamiliarity and judgment. You learn theproblems that can occur during a partic-ular procedure or with a particular condi-tion, and you learn how to either preventor respond to those problems.

Say you've got a patient who needssurgery for appendicitis. These days, sur-geons will typically do a laparoscopicappendectomy. You slide a small cam-era---a laparoscope--into the abdomenthrough a quarter-inch incision nearthe belly button, insert a long grasperthrough an incision beneath the waist-line, and push a device for stapling andcutting through an incision in the leftlower abdomen. Use the grasper to pickup the finger-size appendix, fire the sta-pler across its base and across the vesselsfeeding it, drop the severed organ into aplastic bag, and pull it out. Close up, andyou're done. That's how you like it to go,anyway. But often it doesn't.

Even before you start, you need tomake some judgments. Unusual anat-omy, severe obesity, or internal scarsfrom previous abdominal surgery couldmake it difficult to get the camera insafely; you don't want to poke it into aloop of intestine. You have to decidewhich camera-insertion method to use--there's a range of options--or whether toabandon the high-tech approach and dothe operation the traditional way, with awide-open incision that lets you see ev-44 ~~. 'rOIlKEI\,0C'r0IEI\3. tel.;

ANNALS OF MEDICINE

PERSONAL BESTT op a th le te s a nd sin ge rs h av e c oa ch es. S ho uld y ou ?

BYATUL GAWANDEerything directly. If you do get your cam-era and instruments inside, you may havetrouble grasping the appendix. Infectionturns it into a fat, bloody, inflamed wormthat sticks to everything around it-bowel, blood vessels, an ovary, the pelvicsidewall-and to free it you have tochoose from a variety of tools and tech-niques. You can use a long cotton-tippedinstrument to try to push the surround-ing attachments away. You can use elec-trocautery, a hook, a pair of scissors, asharp-tip dissector, a blunt-tip dissector,a right-angle dissector, or a suction de-vice. You can adjust the operating tableso that the patient's head is down and hisfeet are up, allowing gravity to pull theviscera in the right direction. Or you canjust grab whatever part of the appendix isvisible and pull really hard.

Once you have the little organ in view,you may find that appendicitis was thewrong diagnosis. It might be a tumor ofthe appendix, Crohn's disease, or anovarian condition that happened to haveinflamed the nearby appendix. Thenyou'd have to decide whether you needadditional equipment or personnel-maybe it's time to enlist another surgeon.

Overtime, you learn how to head offproblems, and, when you can't, you arriveat solutions with less fumbling and moreassurance. After eight years, I've per-formed more than two thousand opera-tions. Three-quarters have involved myspecialty, endocrine surgery---surgery forendocrine organs such asthe thyroid, theparathyroid, and the adrenal glands. Therest have involved everything from sim-ple biopsies to colon cancer. For my spe-cialized cases, I've come to know most ofthe serious difficulties that could arise,and have worked out solutions. For theothers, I've gained confidence in myabil-ity to handle a wide range of situations,and to improvise when necessary.

As I went along, I compared my re-sults against national data, and I beganbeating the averages. My rates of compli-,


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seventeen. In the hope of not losing mygame altogether, I play when I can. Ioften bring my racquet on trips, for in-stance, and look for time to squeeze in amatch.

One July day a couple of years ago,when I was at a medical meeting in Nan-tucket, I had an afternoon free and wentlooking for someone to hit with. I founda local tennis club and asked ifthere wasanyone who wanted to play. Therewasn't. I saw that there was a ball ma-chine, and I asked the club pro ifI coulduse it to practice ground strokes. He toldme that it was for members only. But Icould pay for a lesson and hit with him.

He was in his early twenties, a recentgraduate who'd played on his collegeteam. We hit back and forth for a while.He went easy on me at first, and thenstarted running me around. I served a fewpoints, and the tennis coach in him cameout. You know, he said, you could getmore power from your serve.

I was dubious. My serve had alwaysbeen the best part of my game. But I lis-tened. He had me pay attention to my feetas I served, and I gradually recognizedthat my legsweren't rea1lyundemeath mewhen I swung my racquet up into the air.My right leg dragged a few inches behindmy body, reducing my power. With a fewminutes of tinkering, he'd added at leastten miles an hour to my serve. I was serv-ing harder than I ever had in my life.

Not long afterward, I watched RafaelNadal playa tournament match on theTennis Channel. The camera flashed tohis coach, and the obvious struck me asinteresting: even Rafael Nadal has acoach. Nearly every elite tennis player inthe world does. Professional athletes usecoaches to make sure they are as good asthey can be.

But doctors don't. rd paid to have a kidjust out of college look at my serve. Sowhy did I find it inconceivable to paysomeone to come into my operating roomand coach me on my surgical technique?

What we think of as coaching was,sports historians say, a distinctlyAmerican development. During thenineteenth century, Britain had themore avid sporting culture; its leisureclasses went in for games like cricket,golf, and soccer. But the aristocratic or-igins produced an ethos of amateurism:you didn't want to seem to be trying46 THE NEWYORK.ER,OCTOBER3, 2011

too hard. For the Brits, coaching, evenpracticing, was, well, unsporting. InAmerica, a more competitive and en-trepreneurial spirit took hold. In 1875,Harvard and Yale played one of thenation's first American-rules footballgames. Yale soon employed a headcoach for the team, the legendary Wal-ter Camp. He established positioncoaches for individual player develop-ment, maintained detailed performancerecords for each player, and pre-plannedevery game. Harvard preferred the Brit-ish approach to sports. In those firstthree decades, it beat Yale only fourtimes.

The concept of a coach is slippery.Coaches are not teachers, but they teach.They're not your boss-in professionaltennis, golf, and skating, the athlete hiresand fires the coach-but they can bebossy. They don't even have to be goodat the sport. The famous Olympic gym-nastics coach Bela Karolyi couldn't do asplit if his life depended on it. Mainly,they observe, they judge, and they guide.

Coaches are like editors, another slip-pery invention. Consider Maxwell Per-kins, the great Scribner's editor, whofound, nurtured, and published suchwriters as F. Scott Fitzgerald, ErnestHemingway, and Thomas Wolfe. "Per-kins has the intangible faculty of givingyou confidence in yourself and the bookyou are writing," one of his writers saidin a New YorkerProfile from 1944. "Henever tells you what to do," anotherwriter said. "Instead, he suggests to you,in an extraordinarily inarticulate fashion,what you want to do yourself"

The coaching model is different fromthe traditional conception of pedagogy,where there's a presumption that, aftera certain point, the student no longerneeds instruction. You graduate. You'redone. You can go the rest of the wayyourself This is how elite musicians aretaught. Barbara Lourie Sand's book''Teaching Genius" describes the meth-ods of the legendary Juilliard violin in-structor Dorothy DeLay. DeLay wasa Perkins-like figure who trained anamazing roster of late-twentieth-cen-tury virtuosos, including Itzhak Perl-man, Nigel Kennedy, Midori, and SarahChang. They came to the JuilliardSchool at a young age-usually afterthey d demonstrated talent but reachedthe limits of what local teachers could

offer. They studied with DeLay for anumber of years, and then they gradu-ated, launched like ships leaving dry-dock. She saw her role as preparingthem to make their way without her.

Itzhak Perlman, for instance, arrivedat Juilliard, in 1959, at the age of thir-teen, and studied there for eight years,working with both DeLay and IvanGalamian, another revered instructor.Among the key things he learned werediscipline, a broad repertoire, and theexigencies of technique. "All Del.ay'sstudents, big or lillie, have to do theirscales, their arpeggios, their etudes, theirBach, their concertos, and so on," Sandwrites. "By the time they reach theirteens, they are expected to be practicinga minimum of five hours a day." DeLayalso taught them to trynew and difficultthings, to perform without fear. She ex-panded their sense of possibility. Perl-man, disabled by polio, couldn't play theviolin standing, and DeLay was one ofthe few who were convinced that hecould have a concert career. DeLay was,her biographer observed, "basically inthe business of teaching her pupils howto think, and to trust their ability to doso effectively." Musical expertise meantnot needing to be coached.

Doctors understand expertise in thesame way. Knowledge of disease and thescience of treatment are always evolving.We have to keep developing our capa-bilities and avoid falling behind. So thetraining inculcates an ethic of perfec-tionism. Expertise is thought to be not astatic condition but one that doctorsmust build and sustain for themselves.

Coaching in pro sports proceedsfrom a starkly different premise: it con-siders the teaching model naive aboutour human capacity for self-perfection.It holds that, no matter how well pre-pared people are in their formative years,few can achieve and maintain their bestperformance on their own. One of theseviews, it seemed to me, had to be wrong.So I called Itzhak Perlman to find outwhat he thought.

I asked him why concert violinistsdidn't have coaches, the way top athletesdid. He said that he didn't know, butthat it had always seemed a mistake tohim. He had enjoyed the services of acoach all along.

He had a coach? "I was very, verylucky," Perlman said. His wife, Toby,


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whom he'd known at Juilliard, was aconcert-level violinist, and he'd relied onher for the past forty years. "The greatchallenge in performing is listening toyourself," he said. ' 'Your physicality, thesensation that you have as you play theviolin, interferes with your accuracy oflistening." What violinists perceive isoften quite different from what audi-ences perceive."My wife always says that I don't re-ally know how I play," he told me. "Sheis an extra ear." She'd tell him if a passagewas too fast or too tight or too mechan-ical-if there was something that neededfixing. Sometimes she has had to puzzleout what might be wrong, asking an-other expert to describe what she heardas he played.

Her ear provided external judgment."She is very tough, and that's what I likeabout it," Perlman says. He doesn't al-ways trust his response when he listensto recordings of his performances. Hemight think something sounds awful,and then realize he was mistaken:"There is a variation in the ability to lis-ten, as well, I've found." He didn't knowif other instrumentalists relied on coach-ing, but he suspected that many findhelp like he did. Vocalists, he pointedout, employ voice coaches throughouttheir careers.

The professional singers I spoke todescribe their coaches in nearly identicalterms. 'We refer to them as our 'outsideears,' '' the great soprano Renee Berningtold me. ''The voice is so mysterious andfragile. It's mostly involuntary musclesthat fuel the instrument. What we hearas we are singing is not what the audi-ence hears." When she's preparing for aconcert, she practices with her vocalcoach for ninety minutes or so severaltimes a week. "Our voices are very lim-ited in the amount of time we can usethem," she explains. After they've put inthe hours to attain professional status,she said, singers have about twenty orthirty years to achieve something neartheir best, and then to sustain that level.For Fleming, "outside ears" have beeninvaluable at every point.s o outside ears, and eyes, are impor-tant for concert-calibre musiciansand Olympic-level athletes. What aboutregular professionals, who just want todo what they do as well as they can? I

talked to Jim Knight about this. He isthe director of the Kansas CoachingProject, at the University of Kansas. Heteaches coaching-for schoolteachers.For decades, research has confirmed thatthe big factor in determining how muchstudents learn is not class size or the ex-tent of standardized testing but the qual-ity of their teachers. Policymakers havepushed mostly carrot-and-stick reme-dies: firing underperforming teachers,giving merit pay to high performers, pe-nalizing schools with poor student testscores. People like Jim Knight think weshould push coaching.

California researchers in the earlynineteen-eighties conducted a five-yearstudy of teacher-skill development ineighty schools, and noticed somethinginteresting. Workshops led teachers touse new skills in the classroom only tenper cent of the time. Even when a prac-tice session with demonstrations andpersonal feedback was added, fewer thantwenty per cent made the change. Butwhen coaching was introduced-whena colleague watched them try the newskills in their own classroom and pro-vided suggestions---adoption rates passedninety per cent. A spate of small ran-domized trials confirmed the effect.Coached teachers were more effective,and their students did better on tests.

Knight experienced it himself. Twodecades ago, he was trying to teach writ-ing to students at a community collegein Toronto, and floundering. He stud-

ied techniques for teaching studentshow to write coherent sentences and or-ganize their paragraphs. But he didn'tget anywhere until a colleague came intothe classroom and coached him throughthe changes he was trying to make. Hewon an award for innovation in teach-ing, and eventually wrote a Ph.D. disser-tation at the University of Kansas onmeasures to improve pedagogy. Thenhe got funding to train coaches forevery school in Topeka, and he has beenexpanding his program ever since.Coaching programs have now spread tohundreds of school districts across thecountry.

There have been encouraging earlyresults, but the data haven't yet been an-alyzed on a large scale. One thing thatseems clear, though, is that not allcoaches are effective. I asked Knight toshow me what makes for good coaching.We met early one May morning atLeslie H.Walton Middle School, in Al-bemarle County, Virginia. In 2009, theAlbemarle County public schools cre-ated an instructional-coaching program,based in part on Knight's methods. Itre-cruited twenty-four teacher coaches forthe twenty-seven schools in the semi-rural district. (Charlottesville is the countyseat, but it runs a separate school dis-trict.) Many teacher-coaching programsconcentrate on newer teachers, and thisone is no exception. All teachers in theirfirst two years are required to accept acoach, but the program also offers

"T his is o ur c ojJe em ake r ro om . "


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"The check is in the c loud . "

coaching to any teacher who wants it.Not everyone has. Researchers from

the University of Virginia found thatmany teachers see no need for coaching.Others hate the idea of being observedin the classroom, or fear that using acoach makes them look incompetent, orare convinced, despite assurances, thatthe coaches are reporting their evalua-tions to the principal. And some are skep-tical that the school's particular coacheswould be of any use.

To find its coaches, the program tookapplications from any teachers in thesystem who were willing to cross over tothe back of the classroom for a couple ofyears and teach colleagues instead of stu-dents. They were selected for their skillswith people, and they studied the meth-ods developed by Knight and others.But they did not necessarily have anyspecial expertise in a content area, likemath or science. The coaches assignedto Walton Middle School were JohnHobson, a bushy-bearded high-schoolhistory teacher who was just thirty-threeyears old when he started but had beena successful baseball and tennis coach,and Diane Harding, a teacher who hadtwo decades of experience but had spentthe previous seven years out of the class-room, serving as a technology specialist.

Nonetheless, many veteran teach-ers-including some of the best-signed up to let the outsiders in. JennieCritzer, an eighth-grade math teacher,was one of those teachers, and we de-48 THE NEW YOR.KER.,OCTOBER.3, 2011

scended on her first-period algebra classas a small troupe-Jim Knight, me, andboth coaches. (The school seemed eagerto have me see what both do.)

After the students found theirseats-some had to search a little, be-cause Critzer had scrambled the as-signed seating, as she often does, to"keep things fresh" -she got to work.She had been a math teacher at WaltonMiddle School for ten years. She taughtthree ninety-minute classes a day withanywhere from twenty to thirty stu-dents. And she had every class struc-tured down to the minute.

Today, she said, they would be learn-ing how to simplify radicals. She had al-ready put a "Do Now' problem on thewhiteboard: "Simplify- :";36 and :";32."She gave the kids three minutes to get asfar as they could, and walked the rows ofdesks with awhite egg timer in her handas the students went at it. With herblond pigtails, purple striped sack dress,flip-flops, and painted toenails, each adifferent color, she looked like a gradu-ate student headed to a beach party. Butshe carried herself with an air of easycommand. The timer sounded.

For thirty seconds, she had the stu-dents compare their results with those ofthe partner next to them. Then shecalled on a student at random for thefirst problem, the simplified form of:";36."Six," the girl said."Stand up ifyou got six,"Critzer said.Everyone stood up.

She turned to the harder problem ofsimplifying :";32.No one got the answer,4 :";2.It was a middle-level algebra class;the kids didn't have a lot of confidencewhen it came to math. Yet her job was tohold their attention and get them tograsp and apply three highly abstractconcepts-the concepts of radicals, ofperfect squares, and of factoring. In thecourse of one class, she did just that.She set a clear goal, announcing thatby the end of class the students wouldknow how to write numbers like :";32ina simplified form without using a deci-mal or a fraction. Then she broke thetask into steps. She had the studentspunch :";32into their calculators and seewhat number they got (5.66). She hadthem try explaining to their partner howwhole numbers differed from decimals.("Thirty seconds, everyone.") She hadthem write down other numbers whosesquare root was a whole number. Shemade them visualize, verbalize, andwrite the idea. Soon, they'd figured outhow to find the factors of the numberunder the radical sign, and then how tomove factors from under the radical signto outside the radical sign.

Toward the end, she had her studentstry simplifying :";20.They had one min-ute. One of the boys who' d looked alter-nately baffied and distracted for the firsthalf of class hunched over his notebookscratching out an answer with his pencil."This is so easy now," he announced.

I told the coaches that I didn't seehow Critzer could have done better.They said that every teacher has some-thing to work on. Itcould involve stu-dent behavior, or class preparation, ortime management, or any number ofother things. The coaches let the teach-ers choose the direction for coaching.They usually know better than anyonewhat their difficulties are.

Critzer's concem for the last quarter ofthe school year was whether her studentswere effectively engaged and learning thematerial they needed for the state tests. Sothat's what her coaches focussed on.Knight teaches coaches to observe a fewspecifics: whether the teacher has aneffective plan for instruction; how manystudents are engaged in the material;whether they interact respectfully;whether they engage in high-level conver-sations; whether they understand howthey are progressing, or failing to progress.


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Novice teachers often struggle withthe basicbehavioral issues.Hobson toldme of one such teacher, whose studentsincluded a hugely disruptive boy. Hob-son took her to observe the boy in an-other teacher's classroom, where he be-haved like a prince. Only then did theteacher see that her stylewas the prob-lem. She let students speak-and shout,and interrupt-without raising theirhands, and go to the bathroom withoutasking.Then she got angrywhen thingsgot out of control

Jennie Critzer had no trouble main-taining classroom discipline, and sheski11fullysed a variety ofwhat teacherscall "learning structures"-lecturing,problem-solving, cooperative learning,discussion.But the coachesweren't con-vinced that she was getting the best re-sults. Of twenty kids, they noticed, atleast four seemed at sea.Good coaches know how to breakdown performance into its critical indi-vidual components. In sports, coachesfocus on mechanics, conditioning, andstrategy, and havewaysto break each ofthose down, in turn.The u.c.L.A. bas-ketball coach John Wooden, at the firstsquad meeting each season, even had hisplayers practice putting their socks on.He demonstrated just how to do it: hecarefully rolled each sock over his toes,up his foot, around the heel, and pulledit up snug, then went back to his toesand smoothed out the material along thesock'slength, making sure there were nowrinkles or creases. He had two pur-poses in doing this. FIrst, wrinkles causeblisters. Blisters cost games. Second, hewanted his players to learn how crucialseemingly trivial details could be. "De-tails create success"was the creed of acoach who won ten N.C.A.A. men'sbasketball championships.At Walton Middle School, Hobsonand Harding thought that Critzershould pay close attention to the detailsof how she used cooperative learning.When she paired the kids off, they ob-served, most struggled with having a"math conversation." The worst pairshad a girl with a boy. One boy-girl pairhad been unable to talk at all.Elite performers, researchers say,must engage in "deliberate practice"-sustained,mindful efforts to developthefull range of abilities that success re-quires.You have to work at what you're

not good at. In theory, people can dothis themselves. But most people do notknowwhere to start or how to proceed.Expertise, as the formula goes, requiresgoing from unconscious incompetenceto conscious incompetence to consciouscompetence and finally to unconsciouscompetence. The coach provides theoutside eyes and ears, and makes youaware ofwhere you're fallingshort. Thisis tricky. Human beings resist exposureand critique; our brains are well de-fended. So coaches use a variety of ap-proaches-showing what other, re-spected colleagues do, for instance, orreviewingvideos of the subject's perfor-mance. The most common, however, isjust conversation.

At lunchtime, Critzer and her coachessat down at a table in the empty schoollibrary. Hobson took the lead. ''Whatworked?" he asked.Critzer said she had been trying toincrease the time that students spend onindependent practice during classes,andshe thought she was doing a good job.She was also trying to "break the plane"more-get out from in front of thewhiteboard and walk among the stu-dents-and that was working nicely.But she knew the next question, andposed it herself: "So what didn't gowell?"She noticed one girlwho "clearlywasn't getting it." But at the time shehadn't been surewhat to do.

"How could you help her?" Hobsonasked.She thought for a moment. "Iwouldneed to break the concept down forher more," she said. "I'llbring her in during the fifthblock.""What else did younotice?""My second class hasthirty kids but was moreforthcoming. It was actuallyeasier to teach than the firstclass.This group is lessver-bal." Her answer gave the coaches theopening they wanted. They mentionedthe trouble students had with their mathconversations, and the girl-boy pair whodidn't talk at all. "How could you helpthem be more verbal?"

Critzer was stumped. Everyone was.The table fellsilent. Then Harding hadan idea. "How about putting key mathwords on the board for them to use-

like 'factoring,' 'perfect square,' 'radical'?"she said. "They could even record themath words they used in their discus-sion." Critzer liked the suggestion. Itwas something to try.Forhalf anhour, theyworked throughthe fine points of the observation andformulated plans for what she couldpractice next. Critzer sat at a short endof the table chatting, the coaches at thelong end beside her, Harding leaningtoward her on an elbow, Hobsonfingering his beard. They looked likethree colleagues on a lunch break-which, Knight later explained,was partofwhat made the two coaches effective.

He had seen enough coaching tobreak even their performance down intoits components. Good coaches, he said,speak with credibility, make a personalconnection, and focus little on them-selves. Hobson and Harding "listenedmore than they talked," Knight said.'They were one hundred per cent pres-ent in the conversation."They alsopar-celled out their observations carefully."It's not a normal way of communicat-ing-watching what your words aredoing," he said. They had discomfitinginformation to convey, and they did itdirectlybut respectfully.I asked Critzer if she liked thecoaching. "I do," she said. "It workswith my personality. I'm very self-crit-ical. So I grabbed a coach from the be-ginning." She had been concerned fora while about how to do a better jobengagingher kids."Somany things haveto come together. I'd exhausted every-thing I knew to improve."She told me that she had

begun to bum out. "I felt re-ally isolated, too," she said.Coaching had changed that."My stress level is a lot lessnow."That might havebeenthebestnewsforthe students.They kept a great teacher,and sawher get better. "The

coachinghasdefinitelychangedhow sat-isfYingteaching is,"she said.

Iecidedto try a coach.I calledRobertOsteen, a retired general surgeon,whom I trained under during my resi-dency, to see if he might consider theidea. He's one of the surgeons I mosthoped to emulate in my career.His op-erationswere swift without seeming hur-THE NEWYORKER,OCTOBER3, 2011 49


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ried and elegant without seeming showy.He was calm. I never once saw him losehis temper. He had a plan for every cir-cumstance. He had impeccable judg-ment. And his patients had unusuallyfew complications.

He specialized in surgery for tumorsof the pancreas, liver, stomach, esopha-gus, colon, breast, and other organs.One test of a cancer surgeon is knowingwhen surgery is pointless and when toforge ahead. Osteen never hemmed orhawed, or pushed too far. "Can't bedone," he'd say upon getting a patient'sabdomen open and discovering a tumorto be more invasive than expected. And,without a pause for lament, he'd beginclosing up again.

Year after year, the senior residentschose him for their annual teachingaward. He was an unusual teacher. Henever quite told you what to do. As anintern, I did my first splenectomy withhim. He did not draw the skin incisionto be made with the sterile marking penthe way the other professors did. He juststood there, waiting. Finally, I took thepen, put the felt tip on the skin some-where, and looked up at him to see ifIcould make out a glimmer of approval ordisapproval. He gave me nothing. I drewa line down the patient's middle, fromjust below the sternum to just above thenavel.

"Is that really where you want it?"he said. Osteen's voice was a low, car-engine growl, tinged with the accent ofhis boyhood in Savannah, Georgia, andit took me a couple of years to realizethat it was not his voice that scared mebut his questions. He was invariably try-ing to get residents to think-to thinklike surgeons-and his questions ex-posed how much we had to leam.

"Yes," I answered. We proceededwith the operation. Ten minutes intothe case, it became obvious that I'd madethe incision too small to expose thespleen. ''1 should have taken the incisiondown below the navel, huh?" He gruntedin the affirmative, and we stopped to ex-tend the incision.

I reached Osteen at his summerhome, on Buzzards Bay. He was enjoy-ing retirement. He spent time with hisgrandchildren and travelled, and, havingbeen an avid sailor all his life, he had justfinished writing a book on nineteenth-century naval mapmaking. He didn't50 THE NEWYORKER,ocrOBER 3, 2011

miss operating, but one day a week heheld a teaching conference for residentsand medical students. When I explainedthe experiment I wanted to try, he wasgame.

He came to my operating room onemorning and stood silently observingfrom a step stool set back a few feet fromthe table. He scribbled in a notepad andchanged position once in a while, look-ing over the anesthesia drape or watch-ing from behind me. I was initially self-conscious about being observed by myformer teacher. But I was doing an op-eration-a thyroidectomy for a patientwith a cancerous nodule-that I haddone around a thousand times, moretimes than I've been to the movies. I wasquickly absorbed in the flow of it-thesymphony of coordinated movementbetween me and my surgical assistant, asenior resident, across the table from me,and the surgical technician to my side.

The case went beautifully. The can-cer had not spread beyond the thyroid,and, in eighty-six minutes, we removedthe fleshy, butterfly-shaped organ, care-fully detaching it from the trachea andfrom the nerves to the vocal cords. Osteenhad rarely done this operation whenhe was practicing, and I wonderedwhether he would find anything usefulto tell me.

We sat in the surgeons' lounge after-ward. He saw only small things, he said,but, if I were trying to keep a problemfrom happening even once in my nexthundred operations, it 's the small thingsI had to worry about. He noticed thatI'dpositioned and draped the patient per-fectly for me, standing on his left side,but not for anyone else. The drapinghemmed in the surgical assistant acrossthe table on the patient's right side, re-stricting his left arm, and hampering hisability to pull the wound upward. At onepoint in the operation, we found our-selves struggling to see up high enoughin the neck on that side. The drapingalso pushed the medical student off tothe surgical assistant's right, where hecouldn't help at all. I should have mademore room to the left, which would haveallowed the student to hold.the retractorand freed the surgical assistant's left hand.

Osteen also asked me to pay more at-tention to my elbows. At various pointsduring the operation, he observed, myright elbow rose to the level of my shoul-

der, on occasion higher. ''You cannotachieve precision with your elbow in theair," he said. A surgeon's elbows shouldbe loose and down by his sides. ''Whenyou are tempted to raise your elbow, thatmeans you need to either move yourfeet"-because you're standing in thewrong position-"or choose a differentinstrument."

He had a whole list of observationslike this. His notepad was dense withsmall print. I operate with magnifyingloupes and wasn't aware how much thisrestricted my peripheral vision. I nevernoticed, for example, that at one Pointthe patient had blood-pressure prob-lems, which the anesthesiologist wasmonitoring. Nor did I realize that; forabout half an hour, the operating lightdrifted out of the wound; I was operat-ing with light from reflected surfaces.Osteen pointed out that the instrumentsI'd chosen for holding the incision openhad got tangled up, wasting time.

That one twenty-minute discussiongave me more to consider and workon than I'd had in the past five years. Ithad been strange and more than a littleawkward having to explain to the surgi-cal team why Osteen was spending themorning with us. "He's here to coachme," I'd said. Yet the stranger thing, itoccurred to me, was that no senior col-league had come to observe me in theeight years since I'd established my sur-gical practice. Like most work, medicalpractice is largely unseen by anyone whomight raise one's sights. I'd had no out-side ears and eyes.

Osteen has continued to coach me inthe months since that experiment. I takehis observations, work on them for a fewweeks, and then get together with himagain. The mechanics of the interactionare still evolving. Surgical performancebegins well before the operating room,with the choice made in the clinic ofwhether to operate in the first place.Osteen and I have spent time examiningthe way I plan before surgery. I've alsobegun taking time to do something I'drarely done before-watch other col-leagues operate in order to gather ideasabout what I could do.

A former colleague at my hospital, ~the cancer surgeon Caprice Greenberg, ~has become a pioneer in using video in ~the operating room. She had the idea ~


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that routine, high-quality video record-ings of operations could enable us tofigureout why somepatients fare betterthan others. If we learned what tech-niques made the difference, we couldeventry to coach for them. The work isstill in its early stages. So far, a handfulof surgeons have had their operationstaped, and begun reviewing them with acolleague.I was one of the surgeonswho got totry it. It was likegoing overa game tape.One rainy afternoon, I brought my lap-top to Osteen's kitchen, and wewatcheda recordingof another thyroidectomy I'dperformed. Three video pictures of theoperation streamed on the screen--onefrom a camerain the operating light, onefrom awide-angle room camera, andone with the feed from the anesthesiamonitor. A boom microphone pickedup the sound.Osteen likedhow I'd changed the pa-tient's positioning and draping. "See?Right there!" He pointed at the screen."The assistant is able to help you now."At one point, the light drifted out of thewound and wewatched to seehow longit tookme to realizefd lost directillumi-nation: four minutes, instead of half anhour."Good," he said."You'repayingmoreattention."

He had new pointers for me. Hewanted me to let the residents strugglethirty seconds more when I asked themtohelpwith atask I tended togivethemprecise instructions as soon as progressslowed. "No, use the DeBakey forceps,"

I'd say,or "Move the retractor first."Os-teen's advice: "Get them to think" It'sthe onlywaypeople learn.And together we identified a criti-cal step in a thyroidectomy to work on:finding and preserving the parathyroidglands-four fatty glands the size of ayellowsplit pea that sit on the surfaceofthe thyroid gland and are crucialfor reg-ulating a person's calcium levels. Therate at which my patients sufferedper-manent injury to those little organs hadbeen hovering at two per cent. Hewanted me to try lowering the risk fur-ther by finding the glands earlier in theoperation.Since I have taken on a coach, mycomplication rate has gone down. It'stoo soon to know for sure whetherthat's not random, but it seems real. Iknow that I'm learning again. I can't saythat everysurgeon needs a coach to dohis or her best work, but I've discoveredthat I do.

Coaching has become a fad in re-cent years. There are leadershipcoaches, executivecoaches, lifecoaches,and college-application coaches.Searchthe Internet, and you'llfind that there'seven Twitter coaching. ('Would youlike to learn how to get new customers/clients, make valuable business con-tacts, and increase your revenue usingTwitter? Then this Twitter coachingpackage is perfect for you"-at abouteight hundred dollars for a few hour-long Skype sessions and some e-mailconsultation.) Self-improvement has

alwaysfound a ready market, and mostofwhat's on offer is simply one-on-oneinstruction to get amateurs through theessentials. It's teaching with a trendiername. Coaching aimed at improvingthe performance of people who are al-readyprofessionals is lessusual. It's alsoriskier: bad coaching can make peopleworse.

The world-famous high jumperDick Fosbury, for instance, developedhis revolutionary technique-known asthe Fosbury Flop-in defiance of hiscoaches. They wanted him to stick tothe time-honored straddle method ofgoing over the high bar leg first, facedown. He instinctively wanted to goover head first, back down. It was onlyby perfecting his odd technique on hisown that Fosbury won the gold medalat the 1968Mexico City Olympics, set-ting a new record on worldwide televi-sion, and reinventing high-jumpingovernight.Renee Fleming told me that whenher original voice coach died, ten yearsago, she was nervous about replacingher. She wanted outside ears, but theycouldn't be just anybody's. "At mystage, when you're at my level, youdon't reallywant to go to a new personwho might mess things up," she said."Somebody might say, 'You know,you'vebeen singing that way for a longtime, but why don't you trythis?'lfyoulose your path, sometimes you can'tfind your way back, and then you loseyour confidence onstage and it reallyisjust downhill."The sort of coaching that fosters ef-fective innovation and judgment, notmerelythe replication of technique, maynot be so easyto cultivate.Yet modemsocietyincreasinglydepends on ordinarypeople taking responsibility for doingextraordinary things: operating insidepeople's bodies, teaching eighth gradersalgebraic concepts that Euclid wouldhave struggledwith, building a highwaythrough a mountain, constructing awireless computer network across astate, running a factory,reducing a city'scrime rate. In the absence of guidance,how many people can do such complextasks at the levelwe require?With a di-ploma, a fewwill achievesustainedmas-tery; with a good coach, many could.We treat guidance for professionals as aluxury-you canguesswhat gets cut first


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when school-districtbudgets areslashed.But coachingmay prove essential to thesuccessofmodem society.

There was a moment in sports whenemploying a coach was unimagina-ble-and then came a time when notdoing so was unimaginable. We careabout results in sports, and if we carehalf as much about results in schoolsand in hospitals we may reach the sameconclusion. Local health systems mayneed to go the way of the Albemarleschool district. We could create coach-ing programs not only for surgeons butfor other doctors, too--internists aim-ing to sharpen their diagnostic skills,cardiologists aiming to improve theirheart-attack outcomes, and all of uswho have to figure out ways to use ourresources more efficiently. In the pastyear, Ive thought nothing of asking myhospital to spend some hundred thou-sand dollars to upgrade the surgicalequipment I use, in the vague hope ofgiving me finer precision and reducingcomplications. Avoidingjust one majorcomplication saves, on average, four-teen thousand dollars in medicalcosts-not to mention harm to ahuman being. So it seemsworth it. Butthe three or four hours I've spent withOsteen each month have almost cer-tainly added more to my capabilitiesthan any of this.Talk about medical progress, andpeople think about technology. Weawait every new cancer drug as if it willbe our salvation.We dream ofpersonal-ized genomics, vaccines against heartdisease,and the unfathomed efficienciesfrom information technology. I wouldnever deny the potential value of suchbreakthroughs. My teen-age son wasspared high-risk aortic surgery a coupleof years ago by a brief stent procedurethat didn't existwhen he was born. Butthe capabilities of doctors matter everybit as much as the technology. This istrue of all professions. What ultimatelymakes the difference is how wellpeopleuse technology. We have devoted disas-trously little attention to fostering thoseabilities.

A determined effort to introducecoaching could change this. Makingsurethat the benefits exceedthe costwilltake work, to be sure. So will findingcoaches-though, with the growingpool of retirees, we may already have a

ready reserveof accumulated experienceand know-how. The greatest difficulty,though, may simply be a profession'swillingness to accept the idea.The pros-pect of coaching forces awkward ques-tions about how we regard failure. Ithought about this after another caseofmine that BobOsteen cameto observe.Itdidn't go sowell.

The patient was a woman with alarge tumor in the adrenal glandatop her right kidney, and I had decidedto remove it using a laparoscope. Somesurgeonsmight have questioned this de-cision.When adrenal tumors get to be acertain size, they can't be removed lapa-roscopically-you have to do a tradi-tional, open operation and get yourhands inside. I persisted, though, andsoon had causefor regret. Working myway around this tumor with a ten-milli-metre camera on the end of a foot-and-a-half-Iongwand was like trying to findmy way around a mountain with a pen-light. I continued with myfollytoo long,and causedbleeding in a blind spot. Theteam had to giveher ablood transfusionwhile I opened her belly wide and didthe traditional operation.Osteen watched, silent and blank-faced the entire time, taking notes. Mycheeksburned; I wasmortified. I WishedI'd never asked him along. I tried to berational about the situation-the patientdid fine. But I had let Osteen see myjudgment fail;I'd let him see that I maynot be who I want to be.This is why it will never be easyto submit to coaching, especially forthose who are well along in their ca-reer. I'm ostensibly an expert. I'd fin-ished long ago with the days of beingtested and observed. I am supposed tobe past needing such things. Whyshould I expose myself to scrutiny andfault-finding?

I havespokento other surgeonsaboutthe idea. "Oh, I can think of a few peo-ple who could use some coaching" hasbeen a common reaction. Not many say,"Man, could I use a coach!" Once, Iwouldn't have, either.

Osteen and I sat together after theoperation and broke the case down,weighing the decisions I'd made at var-ious points. He focussed on what Ithought went well and what I thoughtdidn't. He wasn't sure what I ought to

have done differently, he said. But heaskedme to think harder about the anat-omy of the attachments holding thetumor in.

"You seemedto have trouble keepingthe tissue on tension," he said. He wasright. You can't free a tumor unlessyoucan lift and hold taut the tissue planesyou need to dissect through. Early on,when it had become apparent that Icouldn't see the planes clearly, I couldhave switched to the open procedure be-foremy poking around causedbleeding.Thinking back, however, I also realizedthat there was another maneuver I couldhave tried that might have let me holdthe key attachments on tension, andmaybe evenfreed the tumor."Most surgery is done in your head,"Osteen likes to say.Your performance isnot determined by where you stand orwhere your elbow goes. It's determinedbywhere you decide to stand,where youdecide to put your elbow.I knew that hecould drive me to make smarter deci-sions,but that afternoonI recognizedtheprice: exposure.For society,too, there areuncomfort-able difficulties: we may not be readyto accept--or pay for-a cadre of peo-ple who identify the flaws in the profes-sionalsuponwhom we rely,and yet holdin confidence what they see. Coachingdone well may be the most effective in-tervention designed for human perfor-mance. Yet the allegiance of coaches isto the people they work with; their suc-cessdepends on it. And the existence ofa coach requires an acknowledgmentthat even expert practitioners have sig-nificant room for improvement. Are weready to confront this factwhen we're intheir care?"Who's that?" a patient asked me asshe awaited anesthesia and noticed Os-teen standing off to the sideof the oper-ating room, notebook inhand.I was flummoxed for a moment. He, wasn't a student or a visiting professor.Calling him "an observer"didn't soundquite right, either."He'sa colleague,"I said."Iaskedhimalong to observeand see ifhe sawthingsI could improve."

The patient gave me a look that wassomewhere between puzzlement andalarm.

"He's like a coach,"I finallysaid.She did not seemreassured.THENEWYOI\KEI\,OClDBEI\ 3, 2011 53

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