A surgeon’s meditations on the learning process

When we were expecting our daughter, one of the first classes we took was an infant and child CPR class. We practiced on mannequins. We were told how to give compressions to the chest; how to tilt the head to open the airway (but not too much); how to give blows in between the shoulder blades while holding the baby such that the head is lower than the rest of the body, in case of choking, and so on. After all the practice, after trying it several times under the supervision of the instructor, after checking out CPR instruction video from the library and watching it several times, we still were not comfortable about performing it on a child.

What if the procedure needed is much more complicated than a simple CPR or Heimlich manoeuvre? What if there are no mannequins to practice? Worse still, what if you have to practice on people? What if you have to watch the complex procedure just once, and repeat it?

I recently read an essay by Atul Gawande titled The learning curve (which is available here as an audio file), which talks precisely about such a scenario, and the ethical and practical problems associated with it.

Learning curve is a must read (if you can’t find a hard copy, a must-hear) essay; it is a bit old–published in January 28, 2002 issue of New Yorker–I read it from the The Best American Essays 2003, edited by Anne Fadiman.

It talks about the need for practice in surgery:

In surgery, as in anything else, skill, judgment, and confidence are learned through experience, haltingly and humiliatingly.

But the catch is,

we practice on people.

And, with that comes the moral burden:

In medicine, there has long been a conflict between the imperative to give patients the best possible care and the need to provide novices with experience.

It becomes much worse when not all patients are the material for practice:

Doctors have no illusions about this. When an attending physician brings a sick family member in for surgery, people at the hospital think twice about letting trainees participate. (…) Conversely, the ward services and clinics where residents have the most responsibility are populated by the poor, the uninsured, the drunk, and the demented.

Having said that, are there studies to show which practices expedite the process of learning? Yes:

We can do things that have a dramatic effect on our rate of improvement — like being deliberate about how we train, and about tracking progress, whether with students and residents or with senior surgeons and nurses.

However, there is also some bad news:

No matter how accomplished, surgeons trying something new got worse before they got better, and the learning curve proved longer, and was affected by far more complicated range of factors, than anyone had realized.

No wonder, Gawande himself was to practice discrimination:

… The young physician looked crestfallen. It was nothing against him, I said. She just had more experience, that was all.

“You know, there is always an attending backing me up,” he said. I shook my head.

I know this was not fair. My son had an unusual problem. The fellow needed the experience. As a resident, I of all people should have understood this. But I was not torn about the decision. This was my child. Given a choice, I will always choose the nest care I can for him.

So, what would be fair?

If everyone cannot have a choice, maybe it is better if no one can.

The piece begins with Gawande’s learning a fairly complex procedure, and ends with his teaching it to another resident (indicating that after all these meditations, things continue the same way).

On the whole, The learning curve is an extraordinary piece; I am placing Gawande along with Sacks and Ramachandran as one of the must-read medical men (also, like Sacks and Ramachandran, one of the best writers among medical men).

Hunt down the article; if you are not able to find a hard copy, you can always listen to the piece — it is an hour well worth spent.

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