Here’s how to become exceptional

You would expect doctors, for the sake of their patients, to do their job well. You would expect doctors that have dedicated their lives to the study of medicine – through medical school and a long residency program – to almost uniformly reach the highest degree of expertise.

A new study by Dr. Birkmeyer and colleagues, published in the New England Journal of Medicine, dares to ask interesting questions: are there significant differences in the abilities of fully-trained doctors? And if so, do these differences make a difference in terms of their patients’ outcomes?

This is how the study was conducted: twenty bariatric surgeons (surgeons specializing in the treatment of obesity) submitted a single videotape of themselves performing laparoscopic gastric bypass. To prevent any bias, the identity of the performing surgeon was concealed. These videotapes were then viewed by their peers, also bariatric surgeons, and rated. The raters judged the gentleness of the performing surgeons, the quality of the their surgical exposure of tissues, the way they handled surgical instruments, the smoothness of their motions, and the flow of the operation. The general surgical skill of each of the operating surgeons was then summarized by giving each performing surgeon a score.

Reassuringly, none of the surgeons flunked the test (the lowest score, 2.6 on a scale of 1 to 5, was higher than the skill level expected from a surgeon toward the end of his training). On the other hand, only a few surgeons reached a score close enough to that representing the skill level of a master-surgeon.

Am I surprised by the observed difference in surgeons’ skills? Not at all. First, because it just follows the laws of logic: people differ from each other; doctors are people; and therefore doctors differ from each other. And second, because I have observed and collaborated with quite a few surgeons in my life, and I can attest that some surgeons are exceptional (I call them naturals, short for natural talents): they press the scalpel onto the patient and the skin submits; they attack human maladies with strategy and might; they navigate using anatomy as their map; they cut gently, handle with care, and sew precisely; and as they leave, they bring tissues together, perfectly mended. And then there are other surgeons…

Does the observed difference in surgeons’ skill (the art, the beauty of surgery) translate into actual difference in patients’ outcomes? Once the performing surgeons in Birkmeyer’s study were divided into 3 groups of expertise, it became clear that surgeons’ skill had a major impact on patients’ outcomes. Compared with patients treated by the highest-score group of surgeons, patients treated by the lowest-score group were according to the study “at least twice as likely to die, have complications, undergo re-operations and be readmitted after hospital discharge.”

If surgical skills are so important, one wonders what factors are associated with higher surgical skills. According to the study, it is not the number of years a doctor spent in practice, or whether he had fellowship training (advanced training following a residency program), nor is it related to her affiliation with a teaching hospital. What is it, then?

Before I reveal the answer, I will tell you about Malcolm Gladwell and his book “Outliers, The Story of Success.” In it, Gladwell examines the factors that contribute to the extreme success (therefore the name ‘Outliers’) of individuals such as elite hockey players, Bill Gates, and The Beatles. Gladwell’s conclusion: the key to success is practicing a specific task for a total of at least 10,000 hours.

Birkmeyer’s study does support Gladwell’s conclusion. It seems that in order to become a great success as a surgeon, one should accumulate a greater number of hours performing surgery: “Surgical skill was,” Birkmeyer states, “strongly related to procedure volume.” The highest-score surgeons performed 241 bariatric procedures a year compared with 106 procedures a year in the lowest-score group.

Could you become exceptional at what you do for a living, or in what you do for fun? Would 10,000 hours suffice? Here is my recipe: first, take advantage of the variability in human talent and choose a field in which your natural talent shines (look at me, for example, and it would become immediately evident that no matter how long I practice, my chances to become a prima ballerina are slim).

Then, work hard to develop your abilities. And with a little luck (the right place, the right time, etc.), you too may become exceptional. Sounds complex? Difficult? It is because becoming exceptional is, well, the exception.

Editor’s note: Dr. Shahar Madjar is a urologist at Bell Hospital in Ishpeming. Read and comment on prior columns by Dr. Madjar at