A gift or hard graft?
In the early 90s, the psychologist K Anders Ericsson and two colleagues set up shop at Berlin’s elite Academy of Music. With the help of the academy’s professors, they divided the school’s violinists into three groups. The first group were the stars, the students with the potential to become world-class soloists. The second were those judged to be merely “good”. The third were students who were unlikely ever to play professionally, and intended to be music teachers in the school system. All the violinists were then asked the same question. Over the course of your career, ever since you first picked up the violin, how many hours have you practised?
Everyone, from all three groups, started playing at roughly the same time – around the age of five. In those first few years, everyone practised roughly the same amount – about two or three hours a week. But around the age of eight real differences started to emerge. The students who would end up as the best in their class began to practise more than everyone else: six hours a week by age nine, eight by age 12, 16 a week by age 14, and up and up, until by the age of 20 they were practising well over 30 hours a week. By the age of 20, the elite performers had all totalled 10,000 hours of practice over the course of their lives. The merely good students had totalled, by contrast, 8,000 hours, and the future music teachers just over 4,000 hours.
The curious thing about Ericsson’s study is that he and his colleagues couldn’t find any “naturals” – musicians who could float effortlessly to the top while practising a fraction of the time that their peers did. Nor could they find “grinds”, people who worked harder than everyone else and yet just didn’t have what it takes to break into the top ranks. Their research suggested that once you have enough ability to get into a top music school, the thing that distinguishes one performer from another is how hard he or she works. That’s it. What’s more, the people at the very top don’t just work much harder than everyone else. They work much, much harder.
This idea – that excellence at a complex task requires a critical, minimum level of practice – surfaces again and again in studies of expertise. In fact, researchers have settled on what they believe is a magic number for true expertise: 10,000 hours.
“In study after study, of composers, basketball players, fiction writers, ice-skaters, concert pianists, chess players, master criminals,” writes the neurologist Daniel Levitin, “this number comes up again and again. Ten thousand hours is equivalent to roughly three hours a day, or 20 hours a week, of practice over 10 years… No one has yet found a case in which true world-class expertise was accomplished in less time. It seems that it takes the brain this long to assimilate all that it needs to know to achieve true mastery.”
Being a great physician requires more than knowledge. Each year we see very bright interns. They can answer questions on a standardized test. They can discuss pathophysiology brilliantly. But the best interns will improve during their training. Senior residents have greater wisdom and clinical instincts. Experienced attending physicians provide help to even the best residents. They provide help and training even though the resident has more up to date knowledge.
What makes a great physician? Obviously, you must start with enough intelligence. You need a desire to learn medicine. Then you need experience. Then you need feedback.
To become a great physician you need to care for many patients, and have feedback, both positive and negative, on your decision making. Those who become great physicians use patient outcomes to learn. They seek realistic critiques for the purpose of growing.
The current proposals for decreasing resident work hours run the risk of this major unintended consequence. Residents cannot become the physicians we want them to become without spending enough time in patient care. We must consider lengthening the duration of training if we must decrease hours further.
Finally, the number of hours required to achieve expertise reminds us why mid-level providers cannot replace physicians. They have inadequate clinical training, especially for primary care. Mid-level providers have great value when working closely with experienced physicians. I believe that they do best with a narrower range of content, that is working with a subspecialist. Primary care is not simple. The problem with primary care occurs because you spend enough time in the short head, that you need much experience to recognize that you have entered the long tail.
When I have a medical problem, I hope my physicians have adequate experience. I hope their training was not short changed.
