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Ever watch an expert do something and then try it yourself? Never as easy at it looks right? Whether it's Stephen Curry sinking a three-pointer, Emeril the chef creating a delicious meal, or Yo Yo Ma playing the cello, experts in their respective fields take what is invariably a highly complex activity and make it look simple. One of my personal favorites was Michelle Kwan, the Olympic medalist figure skater, who took the act of skating on a pair of blades 4mm thick and making it look like anyone could do it.
 Perhaps my first exposure to this was as a podiatric medical student during my third year clinical rotations. I had the pleasure of observing a bunionectomy procedure done by one of my attendings who had attained expertise years before I even thought of becoming a podiatrist. What was so impressive was the manner in which he performed the initial dissection. He barely seemed to move his knife yet the tissue parted like Moses and the Red Sea.
What made this look easy? What do experts do to create that easy-looking appearance?
If you think about it, this is an important question, especially if you're involved with teaching or instruction of any kind. In my job, I spend a lot of time instructing residents and students of various levels who are working to create competence and expertise. For me, this is an issue that comes up almost daily.
Knowledge
Understanding of the important concepts (the "big picture") is a must, but the knowledge of the expert must go beyond the basics and incorporate a full view of the intricate details and their relationship to the major concepts. Take, for example, the surgical skill of bone fixation. Expertise requires not just an understanding of the basic AO principles of fixation, but also the details such as screw anatomy and the specific ways in which various types of screws and other fixation methods perform (besides the mechanics of actually inserting a piece of hardware).
Pattern Recognition
Cognitive research has demonstrated repeatedly that one of the differences between the novice and the expert is the ability to recognize key patterns. This allows for a much more rapid and effective approach to the problem at hand.
All of my partners at the College have had the experience of seeing a patient with a student who has no idea what the diagnosis is. The attending doctor walks in, speaks to the patient for all of ten seconds, and has the diagnosis. The student is surprised at how fast the attending diagnosed the problem. Is it magic? Is the attending a genius? Probably not. In reality, the attending has the knowledge and experience to pick out the most important parts of the patient's history and see the larger pattern of the problem. It's not magic or genius. It's knowledge and experience.
Deliberate Practice with Focused Feedback
 Malcolm Gladwell, in his excellent book Outliers discussed the importance of practice on the attainment of expertise. He discussed the idea of 10,000 hours before one becomes an expert. This of course gets to the whole residency training controversy about Minimum Activity Volume (MAV). We know that it takes a certain number of hours and perhaps repetitions to become proficient – or expert – but how many is that in reality? Are repetitions in a simulator sufficient? No one really knows the answer.
However, it's more, than simply repeatedly practicing many times. Direct, specific, focused feedback is necessary. I could do a bunionectomy procedure 1,000 times, but if I do it wrong every time, I'm simply reinforcing poor behaviors and will never get to expertise.
I was taught quite some time ago to do surgical hand ties. However, as a podiatrist, I've had little use for hand ties outside of some specific indications and thus lack the repetition for true expertise. Additionally, during my training, I received little feedback on this particular skill, so never honed my technique. Now, I can do hand ties, but not with the level of expertise of a general or vascular surgeon who does it all the time.
When working with my residents, I attempt to give them specific feedback during a procedure as soon after as possible. For example, one exercise I like to have them do is to complete a procedure (or part of one) with as few motions as possible, in order to hone their economy of motion. I also ask them to look only at the surgical field. This combination of activities will force them to rely on their scrub tech and not take instruments off the table themselves (a bad habit in my opinion). This also decreases the wasted time between parts of the procedure that improves surgical time. They receive constant feedback during the surgery and rapidly improve as a result.
Analysis
Along a similar line as knowledge and focused feedback, an important and underutilized aspect of training is analysis. Critically reviewing what happened during a learning activity is very important to working out those errors before they become bad habits. This also builds knowledge and critical thinking skills. Each week, my residents and I review the radiographs from the prior week's surgical cases, discussing everything from indications to techniques to errors, always with the intent on improving and learning from our mistakes. This kind of analysis allows me to evaluate my residents' knowledge levels, while also pointing out different ways to do something.
 One analytical method that I hope to employ in the future is the head-mounted video camera. Imagine having a camera tape your every move while performing some skill-based activity and using this to critique your methods. Reviewing the movements during a procedure can be beneficial in the same manner that this is used in sports with the instant replay. Clearly there's a role for technology in creating expertise.
This constant return to basic and advanced skills and knowledge with analysis allows all of us to improve, whether novice, proficient, or expert. This is how the experts make it look easy. Try your hand at these methods and see how you improve.
Best wishes,
Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]
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