Monday, September 21, 2015

Gladwell says just about any college grad could become a cardiac surgeon

"I honestly think that…the overwhelming majority of college grads, given the opportunity, could be better-than-average cardiac surgeons," said pop author Malcolm Gladwell in a discussion with David Epstein. Gladwell qualified his astonishing statement by stipulating that it could only occur with 10,000 hours of deliberate, highly structured practice by very motivated people.

Epstein, author of "The Sports Gene," challenged Gladwell to produce some evidence to support his opinion regarding cardiac surgeons. Instead of evidence, Gladwell replied, "I have a very low opinion of the difficulty of cardiac surgery" and equated the complexity of cardiac surgery with that of driving a car.

If you don't believe me, watch a few minutes of this video, which I have cued to the start of his comments about cardiac surgery.

Both Gladwell and Epstein are somewhat off base. While there is no question that doing operations on the heart requires psychomotor skills, there is much more to it.

Like all procedural specialties, cardiac surgery involves deciding who would benefit from an operation, when should the operation be done, who would be better served without an operation, and what should be done if an unexpected finding or a complication occurs either during surgery or in the postoperative period.

Equating driving a car with performing cardiac surgery is absurd. Most of the time, driving does not require intense concentration. Nearly everyone has had the experience of driving a car on a highway for several miles and realizing that they have no recollection of the scenery or any other vehicles that may have passed going the other way.

Not so with cardiac surgeons, who do not have the luxury of "zoning out."

The "10,000 hours" rule has been challenged by many including David Epstein in his book. If you don't have time to read that book, here is a link to a blog called "The Science of Sport" by Ross Tucker, a PhD in exercise physiology. Do not be put off by the length of the piece, which is worth the few minutes spent reading it. He explains how the original research on the topic of 10,000 hours by psychologist Anders Ericsson was flawed.

And here's an article from Salon called " Ditch the 10,000 hour rule!" that says approaches to learning other than massed practice yield better results.

Finally if hard work and time expended is all it takes to be an expert, my tennis game should be a lot better than it is.

One true statement Gladwell made in the video was, "This is going to offend all medical doctors in the room." But he should have added that it would also offend anyone who is a rational thinker.

This post originally appeared on Physician's Weekly on 11/3/14. It has been revised and updated.


Anonymous said...

I once saw a comment - practice does not make perfect , and used the example of handwriting ! in support of ditch the 10,000 hour rule

William Reichert said...

If you listen to the video, you will find the reasoning Gladwell uses.
His "reasoning" is this:
1. Driving a car is "incredibly complicated" yet everyone can do it.
2. Cardiac surgery is equally complicated but not more so.
3. Therefore since everyone can drive a car, college grads, who
are included in the category of "everyone", obviously also could do cardiac surgery. Go to the equivalent a "drivers ed class" and
To say that driving a car is as difficult as cardiac surgery only
exposes the fact that Mr. Gladwell has no idea what he is talking about. His other writings are full of ideas that contradict each other.
Or are irrational.. Why people listen to him is the real interesting
thing. IN this case, by denigrating the requisite skill required to be a heart surgeon he is tapping into the general public's desire to devalue physicians and hence lower the cost of medicine. Surgery
is simple. Surgeons should be paid like a taxi driver. Start the meter
and make the first incision. What could possibly go wrong?

Anonymous said...

"Finally if hard work and time expended is all it takes to be an expert, my tennis game should be a lot better than it is."

We masters' have a 2 hour period to swim. When you spend about 30-45 min. of that complaining about a too tight suit, how cold it is, swim your warmup lazily, there goes an hour. Give another 10-15 for cool down and final gum flapping. That doesn't include insulting your lane mates during the 10-15 second rest period on laps. Meaning although you can say you had a 2 hour practice, you only worked out for truly 40 min.

PS A surgeon is supposed to have hand/eye coordination and be good with their hands. Hee hee. :)

Anonymous said...

Skeptical, in your experience, what's the distribution of the practice time it takes to become proficient at surgery? Do you think it's a bell curve? Have you come across many 'naturals', 'geniuses', 'grinds' or residents who didn't master it despite heroic efforts?

Anonymous said...

He must be employed by one of the large corporate health programs. This would be right up the new alley that anyone can do anything given sufficient training and motivation. No need to pay for expertise. The problem in the instance of surgery is the need for a desired outcome. You can drive around the block five times and you are still a driver. If you perform 50 surgeries and no one survives are you a surgeon? Me thinks not.

Skeptical Scalpel said...

Great comments all. I agree Gladwell's ridiculous premise fits in with the prevalent attacks on medicine in general and the idea that "anyone can do anything."

I'd say most residents I've had were able learn the procedural skills in the allotted 5 years. Of course some had better hands than others. IMO, the non-procedural stuff (decsision-making, judgement, etc) is harder to learn and takes longer. I was still learning about that up until the day I retired.

frankbill said...

Some years back my brother who runs an auto repair business had a Dr that had a car that had coolant getting into the oil. After many hours of trying DX the problem to Dr was in the shop while my brother was adding coolant to the radiator. Seeing what my brother was doing the Dr ask him what he wad doing. After my brother told him the Dr pointed to oil fill and asked my brother what went in there.

What did this Dr miss during his education?

Skeptical Scalpel said...

That's a great story.

frankbill said...

I don't think the Dr would have been a very good auto mechanic no matter how hours he spent in school.

artiger said...

Frankbill, what if he spent 10,000 hours adding coolant into the radiator?

frankbill said...

Based on a 40 hr work week 10,000 hours is 4.8 years of time. Maybe he would learn where the coolant went after spending almost 5 years worth of time doing it. How many hours will it take him to learn to rebuild the engine?

If you don't have the gift of learning something you will never learn it. Even some most of us use many times a day the smart phone there are some that just can't learn how to use then.

Give me a computer that isn't working right an 95% of the time I will fix it. But give me video game controller and I have no idea on what to do with it.

artiger said...

Frank, my comment was in jest. Sort of.

frankbill said...

What Gladwell says is just jesting. Just as I don't have the eye hand coordination to play video games neither can just about any college grad could become a cardiac surgeon.

artiger said...

OK. Does Gladwell know he was saying it in jest?

Skeptical Scalpel said...

I think he was serious, but it's possible he may have been trolling.

frankbill said...

Gladwell does say something about not being sure if he would want just any cardiac surgeon operating on him.

My take is if one watches the video from the beginning there a few things that they seem to contradict themselves on.

artiger said...

Hmmm...that would suggest elitism. He knows what is best for everyone, until it comes time for him. Then a different standard would apply. He should run for Congress.

Skeptical Scalpel said...

Artiger, great point about elitism.

Anonymous said...

The overwhelming majority could be better than average?

I don't think Gladwell understands the concept of "average."

Sign me, a former art major

Skeptical Scalpel said...

Anon, yes the majority cannot be above average unless those who are below average are way, way below average.

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