Jarrod Shapiro, DPM
Practice Perfect Editor
Assistant Professor
Dept. of Podiatric Medicine
Surgery & Biomechanics
College of Podiatric Medicine
Western University of
Health Sciences
St. Pomona, CA

Thinking or Doing.
Which Is More Important?

When I was a resident, one of my attending surgeons responded to a patient question with an interesting answer. When the patient asked him if the resident would be doing the surgery, his response was something like, "I can train a monkey to do your surgery, but I'll be there doing the thinking which is more important." At the time, I was a little put off hearing this comment. After four years of podiatric medical school and some time as a resident, I thought I had gained unique skills. "How special is my job if a monkey could do it?" I thought.

Thinking or Doing Over time – and more experience – I came to realize the importance of what my attending said. Initially, I failed to consider the second part of his comment, the part about the doctor doing the thinking. What he was really trying to impart, both to the patient and his residents, was the importance of the mind functioning behind the technical part of any surgery.

Today, as an assistant professor, I try to teach my students the importance of thinking and analysis to the practice of medicine and surgery. I was myself reminded of this after a recent surgical procedure I did with one of my third-year students. I allowed the student to do a "skin-to-skin" procedure. The student did a fine job, only requiring me to take the knife for one short moment. Afterward, I was impressed by his equanimity and hand skills (most students don't make it through the beginning of the procedure without me taking over, much less through completion).

Here's a third year podiatric medical student, not even a full three years through training, completing a full surgical procedure. This student's lack of experience, yet ability to perform the manual skills necessary to complete the procedure, emphasizes my prior attending's comments about anyone being able to do surgery.

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With no intent to insult my student – he did do an admirable job – the part he didn't do was think at the level necessary to successfully and independently complete the procedure. For example, he did not determine the appropriate indications for the surgery, prepare the patient preoperatively, didn't mark the incision, didn't constantly reevaluate the intraoperative situation to determine the best way to proceed, and so on. As my old attending said, he was the monkey to my brain.

So, here's the question I worry about as a teacher of students and now residents: is it more important to teach the "doing" or the "thinking"? I also think about this on a national level. Residents are always concerned about doing the highest volume of cases and completing as much of each case as possible. To put a fine point on this, the Council on Podiatric Medical Education (CPME) requires completion of a certain number of procedures for completion of a residency program.

But volume tells us nothing about the cognitive skills of our trainees, and I applaud the CPME for now defining residencies as "competency-based." This is very important, because without actually measuring our trainees' progress, we'll never be able to demonstrate to the medical community the solidity of our skills.

Of course, it's easy to measure competency of technical skills such as performing surgery. It's either done correctly or not. It's either done quickly or slowly. It's more challenging and – dare I say it – less interesting to focus more on the cognitive skills. This is where all skills outside of the operating room are taught with academics such as journal clubs, lectures, case discussions, etc. We need to spend more time with our students and residents, teaching and assessing these mind skills.

Which is more important? Thinking or doing? It's really a trick question, isn't it? Without the thinking, there's no doing. And without the doing, nothing gets done, so the thinking is pointless. Two sides of the same coin, they are. Of course we need to teach both, but we have to avoid the urge to forget about the more challenging cognitive education in exchange for the easier-taught physical education. Like any muscle, the mind has to be exercised, pushed, and developed to gain strength. A mind really is a terrible thing to waste, especially for a doctor.

Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]