I became a laughing stock on social media when I said there are more than 800 surgeries in the Otorhinolaryngology Specialty.  Even I was surprised when I stumbled upon this number.  A few years back, I joined a corporate Hospital as a senior consultant on a fee for service basis.  Earlier, there was no Otorhinolaryngology department there, and I had to establish everything from scratch.  One of the first tasks assigned to me by the finance and billing department was fixing the fee for various Otorhinolaryngology surgeries.  I couldn’t source this information from any other hospital in the city.   So I had to go back to the surgical logbook I had maintained meticulously.  Indeed, I had performed more than 800 types of surgeries until then.  I had performed all the surgeries mentioned in our different textbooks, at least once, with good results and minimum complications.

Medical science has taken a giant leap in the last few decades.  Specialties have given way to subspecialties and super specialties.  The general trend is practicing more and more about less and less!  Necessity is the mother of evolution, and surgeons like me practicing in peripheries cannot restrict to a narrow area of our specialties.  Moreover, there is no cap in our country for the types of surgeries we can perform within our field under appropriate conditions.  Rather, there is a lot of overlap with many other branches of medicine.  

The question here is not the number of surgeries in Otorhinolaryngology.  Many junior colleagues who take part in our training courses ask me, is it possible to learn so many surgeries?   When mastering anything requires a narrow field focus, how can we be proficient in such diverse surgeries of a vast field, such as Otorhinolaryngology? The answer is, as Rome was not built in a day, we cannot attain skills in a short period.  At least during my time.  

Let me illustrate this point by a legend about Pablo Picasso. When Picasso was in the market, a woman charmed by his work approaches him to draw something for her.  Picasso obliges her request, draws a beautiful sketch within a few seconds, and hands it to her.  While the woman adores that drawing, he says, “That will be thirty thousand dollars.” 
The woman is taken aback and protests, “But, Mr. Picasso, how can you charge so much when the drawing has taken only a few seconds.” Mr. Picasso shot back, saying, “Madame, it took me thirty years to learn that art.”    Italian sculptor Michelangelo has said, “If people knew how hard I worked to get my mastery, it wouldn’t seem so wonderful at all.”  

It was not a comfortable journey for me, either.  It took me more than 20 years of an arduous expedition to learn the nuances of these surgeries, one at a time.  It was long and protracted hard work and perseverance to hone these skills like the prolonged work by PWD of Rome!  Even now, I am learning.  The surgical training is comparable to martial arts Karate.  Karate has nine levels of a hierarchy of proficiency, represented by different colors.  A gakusei or a student starts with a white belt.  He becomes a Deshi or top student or Sensei, a teacher or master when he attains the black-belt after training and raising through all levels.  The point to note is that the white belt gakusei gets the same karate training as the black belt gakusei.  The only difference is he has not practiced enough.  The black belt gakusei has the same fundamental skills as white belt gakusei, with ample practice.

Similarly, the surgical field has different surgeries and many levels of learning.  An experienced surgeon is a master or black belt of what he has already learned and a white belt of things he is yet to know.  Like success, mastery is a journey.   As the author of the book the one thing, Gary Keller aptly says, “The path is one of an apprentice learning and learning the basics on a never-ending journey of greater experience and expertise.”   

American author Marianne Williamson once said, “The top of one mountain is always the bottom of another.” A mountaineer doesn’t stop after scaling a mountain.  He goes to the next and the next, the taller ones.  When he goes, he carries all the experience of climbing earlier mountains.  My surgical goals and the journey were akin to a mountaineer.  During the initial period of my career, I focused on one sub-specialty at a time, with deliberate practice, until I reached reasonable mastery.  Here is a slide from one of my presentations, which depicts my Otological journey, which is comparable to a mountaineer. 

Psychologist K. Anderson Ericsson published an article in 1993, “The Role of Deliberate Practice in the Acquisition of Expert Performance” in the journal Psychological Review.  This landmark publication deflated the earlier opinion that expert performers were gifted, naturals, or even prodigies.  Ericsson proposed the “10,000-hour rule” and gave us the first real insights into mastery.  His research concluded that elite performers were the result of a typical regular and deliberate practice pattern over the years.  

Ericsson’s premise was based on his observation of elite violinists who had more than 10,000 hours of practice by age 20.  Malcolm Gladwell’s best selling book, “Outliers” is primarily based on Ericsson’s findings.  “Time on task, over Time, eventually beats talent every time,” says Garry Keller.    According to him, most elite performers accomplish this feat in about ten years, provided they practice deliberately, three hours a day, every day of the year.   If we want to award ourselves some resting or family time and work only 5 or 6 days a week, we need more time.  

With deliberate practice, the American pilots trained at TOP GUN school of TOP GUN movie fame, improved 1,150%!  Earlier, Americans were losing their fighter planes at 1:1 proportions during the Vietnam war. With deliberate practice, they could reduce it to 12.5:1.    

There is an apocryphal story about the Little Master, Sunil Gavaskar, one of the best cricketers the world has seen. His score in test cricket equals the height of Mount Everest in feet.  Even as a child, he was a cricketing prodigy.  As getting him “out” from batting was difficult for his teammates, there was a different set of rules for him. He was called out even if he hits a four or six!  Sunil Gavaskar’s achievements were a result of deliberate practice.  His record of playing all 60 overs during the first match of the first edition of the one-day world cup series with 36 runs, not-out, will remain unbeaten forever.     

Many junior colleagues underestimate themselves thinking, “only a few people are blessed to become good surgeons.”  That’s a wrong assumption.  American Psychiatrist Jose Silva has said,  “I believe that each one of us has been given all of the tools, talent, and training that we need to accomplish the mission we were sent here to do.”  The only thing is that we have to take that first step towards that objective.  

Now, the times have changed, and Ericsson’s 10,000 Hour rule has also been debunked.  Now we have new tools, talent, training, and techniques to master any surgery in lesser time.  We have a curated an online course, “High VOLTage learning,” to help our junior colleagues to become great and versatile surgeons.  The course details will be announced soon. 

With regards, 

Dr. Prahlada N.B
prahlad@kenthospitals.com
www.orlvarsity.com