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Bending the Curve: The Importance of Expertise

2018; Elsevier BV; Volume: 105; Issue: 5 Linguagem: Inglês

10.1016/j.athoracsur.2018.01.040

1552-6259

David R. Jones,

Advances in Oncology and Radiotherapy

I was first introduced to the Southern Thoracic Surgical Association (STSA) during my surgical residency by Gordon Murray, who at that time was the association’s 40th president. In 1993, as a third-year surgery resident, I presented one of my first papers at the STSA [1Jones D.R. Davidson A.G. Summers C.L. Murray G.F. Quinlan D.C. Potential application of p53 as an intermediate biomarker in Barrett's esophagus.Ann Thorac Surg. 1994; 57: 598-603Abstract Full Text PDF PubMed Scopus (58) Google Scholar]. I mention this early academic experience, which occurred nearly 25 years ago, because of the influence it had on my career path and its relevance to the address you have graciously given me the opportunity to share with you today. I would like to recognize several individuals who have been teachers, mentors, sponsors, and friends in my personal and academic lives. During my general surgery residency at West Virginia University, Gordon Murray and Herbert Warden provided my first introduction to academic surgery. During my thoracic surgery residency at the University of North Carolina–Chapel Hill, Dr Ben Wilcox was exacting yet supportive and encouraged my research interests. In 1999, I joined the faculty at the University of Virginia and immediately benefited from working with Irv Kron, past president of both the STSA and the American Association for Thoracic Surgery (AATS), who has been a mentor and friend since I have known him. Finally, I was fortunate to work with Tom Daniel, Chief of Thoracic Surgery, when I arrived, and he was and is a terrific mentor and friend. In 2013, I left the University of Virginia and joined the faculty at Memorial Sloan Kettering Cancer Center. Peter Scardino, Chair of the Department of Surgery, and Murray Brennan, Chair Emeritus of the Department of Surgery, were both immensely helpful in my recruitment and supported me and my ideas for our service. Finally, I want to acknowledge my partners, who I believe are the most talented group of thoracic surgical oncologists in the world (Fig 1). I appreciate the opportunity to work with and learn from them each day. In 1958, Edward Kaplan, a mathematician from the University of California, and Paul Meier, a statistician from the University of Chicago, submitted separate but similar manuscripts to the Journal of the American Statistical Association (Fig 2). The editor, John Tukey—a renowned Bell Labs inventor and Princeton professor—was the prior doctoral advisor of both Edward Kaplan and Paul Meier, and he convinced Kaplan and Meier to combine their work into one paper. This unusual and somewhat forced collaboration took 4 years to complete but resulted in a methodology with a curve that changed the world [2Kaplan E.L. Meier P. Nonparametric estimation from incomplete observations.J Am Stat Assoc. 1958; 53: 457-481Crossref Scopus (48139) Google Scholar]. In cardiothoracic surgery, our patients frequently ask us, “How long will my prosthetic valve last?” “What is the likelihood of dad being alive in 5 years?” In addition to our clinical experience, we use Kaplan-Meier curves to attempt to answer these challenging questions at an individual patient and family level. However, I would submit to you that we more commonly use these curves to measure progress, or lack thereof, in the outcomes of specific diseases that we treat. There are several factors that can affect the curve, including lead-time bias, heterogeneous study populations, different eras of treatment, and, certainly, new therapies. However, if we as thoracic surgeons actually wanted to bend the curve, how could we do it? What would it take? I believe that we begin to bend the curve and improve outcomes for our patients by embracing the quest to become an expert. In fact, there is an emerging science of expertise, and as you will hear, it is not linked to IQ, training institution, or experience or even age. It is this journey of acquiring expertise and the characteristics of experts that we will discuss today. As physicians, we have all received a call or email from a relative, friend, or colleague asking for a recommendation for an expert. The call typically goes, “My wife has a mass in her lung that may be lung cancer. Can you recommend someone who is an expert in this area?” We all want to be cared for by someone who is more than just competent—they are superb. They understand the disease, the surgical and nonsurgical treatment options, they have excellent outcomes, and preferably they are generating and contributing new knowledge to that very specific field. Part of the process of acquiring expertise begins with meeting certain standards—usually in the form of examinations. As thoracic surgeons, we have a long history of taking challenging, high-stakes examination. However, collectively, the most difficult series of examination in the world are those administered by the Transportation Office of London to become a London cab driver. As highlighted in a 2014 article in the New York Times Style Magazine [3Rosen J. The Knowledge, London’s legendary taxi-driver test, puts up a fight in the age of GPS.The New York Times Style Magazine. November 10, 2014; Google Scholar], prospective cabbies spend more than 4 years taking progressively difficult oral and written examinations, log more than 50,000 miles of training runs, and spend literally thousands of hours studying how to most efficiently navigate the labyrinthine 25,000 streets and 12 bridges over the River Thames in Central London. There is no Google, and navigation using GPS is challenging in this poorly laid-out city. This incredible feat of memorizing and developing mental representations has been studied by psychologists and neuroscientists. Maguire and colleagues [4Maguire E.A. Gadian D.G. Johnsrude I.S. et al.Navigation-related structural change in the hippocampi of taxi drivers.Proc Natl Acad Sci U S A. 2000; 97: 4398-4403Crossref PubMed Scopus (2065) Google Scholar] published their findings in the Proceedings of the National Academy of Science in 2000. They found a significant increase in the size of the posterior hippocampus of London cab drivers compared with bus drivers. Importantly, this increase only became apparent on brain imaging after the cab drivers completed the process. This and other similar research has demonstrated that our brains can adapt and change once adulthood is reached and that we are not limited by some predefined capacity for learning. In his recent book Peak: Secrets from the New Science of Expertise [5Ericsson A. Pool R. Peak: Secrets From the New Science of Expertise. Eamon Dolan/Houghton Mifflin Harcourt, New York2016Google Scholar], Anders Ericsson, a psychologist, describes other examples of expertise found in violinists, chess masters, athletes, and, yes, surgeons. Ericsson makes the important observation that experts do more than just practice—they deliberately practice. Characteristics of deliberate practice include a well-defined, focused goal, feedback on performance, and a willingness to stay slightly outside of one’s comfort zone. In essence, instead of trying harder, experts try differently. In addition, studies have shown that expertise is not a function of IQ, age, or even experience. What is uniform in all studies of expertise is that expertise takes time and commitment and that it is goal oriented. It is also well known that cognitive gains made with deliberate practice require maintenance; when we stop practicing, we lose our advantage and move from being expert to just good enough, or worse. Recently, our own STSA member Joe Dearani and colleagues [6Dearani J.A. Gold M. Leibovich B.C. et al.The role of imaging, deliberate practice, structure, and improvisation in approaching surgical perfection.J Thorac Cardiovasc Surg. 2017; 154: 1329-1336Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar] published an Expert Opinion piece in the Journal of Thoracic and Cardiovascular Surgery on the role of deliberate practice, imaging, and structure in their quest for surgical perfection. The authors make the point that the use of technology, particularly three-dimensional imaging and review of operative videos, can enhance deliberate practice and improve performance. In addition—and unsurprisingly, if you know Joe—he also included a section in the article on how deliberate practice intersects with jazz improvisation. Although most of the science behind expertise has focused on deliberate practice and the related concept of “flow,” I would suggest that there are other characteristics—characteristics I have observed in individual surgeons and researchers who I believe are experts in their fields. I recently attended a talk by Roch Parayre, a strategist and member of the Wharton School at the University of Pennsylvania, which reminded me of the tragedy that happened January 28, 1986. On this day, the Space Shuttle Challenger exploded 79 seconds after launch, 9 miles above the earth. This was a very public failure—watched by millions of people on television—and seven people died, including the first teacher who would go to space. However, as later analysis would show, there were weak signals that actually predicted this would happen. Prior studies had identified that the O-rings that seal the hydrogen fuel boosters may not work well in colder temperatures; January 28 was predicted to be a cold morning. Concerned National Aeronautics and Space Administration (NASA) officials gathered the night before the launch. Information was requested and subsequently faxed to NASA by Thiokol, the manufacturer of the O-rings. The data reviewed by NASA the night before the launch only showed the relationship between temperature and O-ring failures; no correlation was identified. On the basis of this information, NASA cleared the launch for the following morning. NASA had asked the question, “Is there any correlation between O-ring failures and ambient temperature?” Wrong question. NASA looked at the times when the O-rings failed but excluded looking at the times when the O-rings were successful. The graph of the full data set—made available only after the Challenger tragedy—shows the clear relationship between O-ring failures and colder temperatures (Fig 3). The temperature the morning of the launch was a chilly 31°F; therefore, the probability of an O-ring failure was nearly 100% and, if known, would have predicted the launch would fail. And tragically it did. There were weak, or perhaps not so weak, signals that were not amplified, and it resulted in tragedy. In cardiothoracic surgery, I have often observed expert surgeons navigate through an amazingly complicated operative procedure with relative ease, whereas others perform the same procedure and it takes twice as long or there are significant complications. Why is this? I believe it has to do with sampling errors, the failure to recognize and appropriately amplify weak signals, ultimately make the correct decisions, and move the case along. When you speak with expert surgeons and ask them how they achieve excellent outcomes, they frequently mention “seeing” things that in isolation appear to be rather innocuous but that in conjunction with other signals result in modification of the procedure and the attainment of the desired outcome for the patient. In addition to amplifying weak signals, experts are generally humble and are not overconfident. Interestingly, it turns out there is some science to suggest that overconfidence can be a significant problem and barrier to developing expertise. In 1999, David Dunning and Justin Kruger [7Kruger J. Dunning D. Unskilled and unaware of it: how difficulties in recognizing one's own incompetence lead to inflated self-assessments.J Pers Soc Psychol. 1999; 77: 1121-1134Crossref PubMed Scopus (3771) Google Scholar] of Cornell University reported the results of a series of clinical trials titled “Unskilled and Unaware of It.”. They subsequently won the 2000 Nobel Prize in Psychology for this work. The Dunning-Kruger effect occurs when people fail to adequately assess their level of competence—or, specifically, their incompetence—at a task and thus consider themselves much more competent than everyone else. As shown in Figure 4, the individual with no expertise is supremely overconfident, sometimes referred to as the “confident idiot.” With increasing expertise, reality sets in with thoughts of, “There is more to this than I thought,” to a low point of, “I am never going to understand it,” to finally an appropriate increase in confidence commensurate with expertise, resulting in the wisdom to know that the task is more complicated than originally thought. In her book Being Wrong: Adventures in the Margin of Error [8Schulz K. Being Wrong: Adventures in the Margin of Error. Ecco, New York2010Google Scholar], Kathryn Schulz makes the point that “it is not in our human nature to even imagine that we are wrong.” Similarly, the court jester Touchstone in Shakespeare’s “As You Like It” differentiates between the fool and the wise man, saying, “The fool doth think he is wise, but the wise man knows himself to be a fool.” In surgery, we observe overconfidence—or, more likely, poor preparedness—when surgeons perform procedures that they do rarely and have little experience with and are unfamiliar with managing the complications that can occur. In contrast, experts appreciate the depth and complexity of the diseases we treat and realize that one treatment approach does not fit all. Another characteristic of experts is that they are more likely to recognize original ideas and their applications. I give you two examples. In 1962, Decca Records turned down the opportunity to manage the Beatles, telling them that they did not like their sound and that groups of guitars were on their way out. John, Paul, Ringo, and George promptly walked across Abbey Road and signed a contract with EMI and Brian Epstein. Epstein saw the potential and originality of the Beatles that nearly every other recording company in London did not. This is not to say, however, that experts are always correct. In 2007, Microsoft’s Steve Ballmer made the wrong call, stating, “That [iPhone] is the most expensive phone in the world. And it doesn’t appeal to business customers because it doesn’t have a keyboard.” The iPhone has now sold more than 1.2 billion units, with $700 billion in revenue and $100 billion in profit. We all lead very busy lives and increasingly are forced to attend to matters unrelated to patient care or research. You may, however, be pleased to learn that this is by no means a new phenomenon. In 1819, 6 years before he won the presidency, 52-year-old John Quincy Adams anticipated Kierkegaard’s proclamation that “of all ridiculous things the most ridiculous [is] to be busy” and lamented the absurdity of ineffectual busyness that animated his days as Secretary of State. As quoted by Adams in his diary, “Every day starts new game to me, upon the field of my duties; but the hurry of the hour leaves me no time for the pursuit of it, and at the close of my Career I shall merely have gone helter-skelter through the current business of the Office, and leave no permanent trace of my ever having been in it” [9Adams J.Q. Memoirs of John Quincy Adams, Comprising Portions of His Diary From 1795 to 1848. J.B. Lippincott & Co, Philadelphia1875Google Scholar]. In another diary entry, penned 15 years earlier, the 37-year-old Adams laments his tendency to lose himself in rabbit holes of what may be interesting but not relevant to his larger aims. He, like experts, understood the meager correlation between effort exerted and results obtained when clarity of purpose is lacking. Even the mightiest discipline, after all, is wasted without a clear direction. Adams mentioned the lure and false promises of rabbit holes. As pointed out by David Sugarbaker in his 2014 AATS Presidential Address, a focus on clarity of purpose and avoiding interesting but diversionary pursuits is an important trait [10Sugarbaker D.J. Clarity of purpose, focused attention: the essence of excellence.J Thorac Cardiovasc Surg. 2014; 148: 764-771Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar]. In addition to that, I believe experts also have an uncanny ability to manage and delegate the busyness to remain true to the larger goals that are more likely to advance the field. Experts also understand the importance of studying and working on important problems. Sir Peter Medawar won the Nobel Prize in 1960 for his pioneering work in graft rejection and acquired immune tolerance, which are the cornerstones of today’s organ transplantation. I have used this quote of his whenever I can over the years. He stated, “Any scientist of any age who wants to make important discoveries must study important problems. Dull or piffling problems yield dull or piffling answers. It is not enough that a problem should be ‘interesting’…. The problem must be such that it matters what the answer is—whether to science generally or to mankind.” I believe this remains true today for all of us, and it is certainly true when pursuing expertise. None of you will argue that we live in an accelerated world. We all have experienced the feelings of stress and powerlessness that living in this fast-paced world can evoke. Information streams in without request, and the demands on our time are seemingly unworkable. As an example, there were 1.3 million biomedical articles published last year alone, having nearly doubled over the past 10 years. We now have more than 6,500 medical journals, and 1,000 of these are related to cardiovascular medicine, surgery, and oncology. How do we keep up with this explosion of new knowledge? Moreover, the world has unfiltered access to us through email, pagers, and cell phones. How do we become experts in this type of environment? One strategy that should be considered when attempting to manage this pace is to step back. Ask yourself this, when have you stepped back in order to slingshot forward? I believe we can and should step back occasionally to change direction, get a fresh look, reallocate bandwidth, and chart a new course. Experts do this because they understand that future progress demands it. When I left the University of Virginia in 2013 to move to Memorial Sloan Kettering Cancer Center, I stepped back. It sounds counterintuitive—sleepy Charlottesville for fast-paced New York. However, I stepped back: building a new clinical practice, totally rebuilding and refocusing the laboratory, and meeting many new people with new ideas. I am not suggesting that you all relocate practices and homes, but some level of situational awareness permits those on the journey for expertise to find ways to restock, change lenses, and focus new energies on our curves. It is well known that a discussion among peers can become heated. However, experts appreciate and actually gravitate toward discussions with other experts about their ideas, plans, outcomes, and next steps. Alfred P. Sloan, cofounder of Sloan Kettering Institute and former chief executive officer of General Motors, perfectly illustrates this point when he stated, “Gentlemen, I take it we are all in complete agreement on the decision here.… Then I propose we postpone further discussion of this matter until our next meeting, to give ourselves time to develop disagreement and perhaps gain some understanding of what the decision is all about” [11Hindle T. Guide to Management Ideas and Gurus (the Economist). 2008 ed. New York City: Bloomberg Press; 2008.Google Scholar]. In thoracic surgery we do this occasionally, but in highly functioning teams of experts from different disciplines, this can happen almost daily, or at least weekly. The result is a better decision, a better direction, and, perhaps, in the case of an individual patient, a better outcome. I believe a culture of healthy, respectful disagreement is mandatory if curves are to be bent and outcomes improved. Even with deliberate practice, the avoidance of rabbit holes, and making the best decisions possible, experts will fail. An illustrative example of an expert who initially failed is that of Sir Paul Nurse, a brilliant student who could not get into graduate school because he failed the required French examination; not just once, but six times. However, a senior scientist took pity on him and offered him a position in his laboratory. After working 6 months in preparation for his first presentation to his doctoral committee, he realized that the amazingly consistent results he had been generating also occurred when he included a control group. Yes, he had been doing all of his prior experiments with no control group. With no time to do anything about this error, he presented his work and acknowledged his egregious mistake. Because of his honesty, and likely his promise as a scientist, he was allowed to continue. He intensified his scientific rigor and went on to identify important mutations in the cyclin dependent kinase 1 gene and discover the cell cycle, for which he won the Nobel Prize in Medicine in 2001. Like Dr Nurse, cardiothoracic surgeons can and do have very public failures—a serious complication, a patient death, a mistake. Experts, however, understand that without failure it is impossible to grow, to move forward. No one generates new knowledge, perfects new surgical approaches, or becomes an expert without failing more times than they succeed. We have discussed many of the characteristics related to developing expertise in cardiothoracic surgery. However, in his recent book The Death of Expertise: The Campaign Against Established Knowledge and Why It Matters [12Nichols T.M. The Death of Expertise: The Campaign Against Established Knowledge and Why It Matters. Oxford University Press, New York2017Google Scholar], Tom Nichols discusses the assault on expertise, some of which clearly applies to our profession. First, we have a Lake Wobegon mentality. As reported by the New York Times in 2013, 50% of medical school curriculum directors admitted to grade inflation, and more importantly greater than 40% said they had given a passing grade when they should have failed the student [13Chen PW. Why failing med students don't get failing grades. The New York Times February 28, 2013. Available at https://well.blogs.nytimes.com/2013/02/28/why-failing-med-students-dont-get-failing-grades/.Google Scholar]. We probably do the same, although hopefully less, in our thoracic surgery residency programs—although we do not admit it. In essence, we all live at Garrison Keillor’s Lake Wobegon, where “all the children are above average.” A second concern is confirmation bias, where we believe what supports our preconceived ideas and dismiss data that challenge what we accept to be the truth. Confirmation bias in medicine, surgery, and research is significant. Examples include the researcher who refuses to believe the data because it does not fit expectations, the surgeon who will not accept the possibility that there is a complication, or the increased numbers of falsified or inaccurate scientific reports published because they are from a prestigious individual or institution. Finally, crowd-sourcing-expertise efforts like Wikipedia have significant limitations in the quality and accuracy of their information, no matter how well intended they may be. It turns out that many of the articles on Wikipedia are generated by companies and public relation firms. The biggest problem with Wikipedia remains a near complete lack of expert peer review. Finally, there is Google. If a patient wants to know the answer to a medical problem, they “Google it.” They then arrive in your office with the diagnosis, treatment plan, and expected survival already established, because they perceive Google and the Internet to be the expert. This immediate and 24-hour-a-day access to poorly vetted information without context remains a significant threat to true medical expertise. Much of today’s literature focuses on expertise at an individual level, but how does expertise really translate into bending the curve? What if we moved expertise for specific diseases under one roof? What happens when we build programs of expertise around the entirety of the disease? Could this approach enhance patient outcomes? In a recent publication in the Journal of the American College of Cardiology [14Carroll J.D. Vemulapalli S. Dai D. et al.Procedural experience for transcatheter aortic valve replacement and relation to outcomes: The STS/ACC TVT registry.J Am Coll Cardiol. 2017; 70: 29-41Crossref PubMed Scopus (178) Google Scholar], Carroll and colleagues examined almost 43,000 transcatheter aortic valve replacement (TAVR) procedures submitted to the Transcatheter Valve Therapy registry, conducted at 395 hospitals from 2011 to 2015, in an attempt to answer the question of whether an association exists between the quality of a procedure’s outcome and the experience of the teams and institutions performing TAVR. The authors found that outcomes, including mortality and bleeding, were all significantly worse at centers where fewer procedures were performed. These results suggest that consideration be given to the development of regional valve centers of excellence, which in turn may improve patient outcomes and ultimately reduce costs. The argument is that complex procedures performed by teams of experts are more likely to yield superior results, from both a patient and a payer perspective. However, do these observations apply to other diseases? Relative to my clinical and research interests, there has been and continues to be an explosion of new knowledge, treatments, and patients in the field of thoracic oncology. Thoracic surgical oncologists are one part of a larger team that generates this new knowledge and then translates it to the individual patient. There is simply no way that one individual, or even one subspecialty, can be an expert in all aspects of this disease. However, when you build programs with teams of experts who are highly specialized and are laser focused on their piece of the puzzle, you can really begin to bend the curve, and you can do it much quicker than you think. In a 2016 publication, Sanhi and colleagues [15Sahni N.R. Dalton M. Cutler D.M. Birkmeyer J.D. Chandra A. Surgeon specialization and operative mortality in United States: retrospective analysis.BMJ. 2016; 354: i3571Crossref PubMed Scopus (86) Google Scholar] hypothesized that subspecialization (read “expertise”) matters. In an effort to understand how much subspecialization may contribute to the volume-outcome curve, risk- and volume-adjusted 30-day operative deaths for eight procedures performed in more than 700,000 Medicare patients from 2008 to 2013 were examined. What is the subspecialization premise? An example is Surgeon A does 40 mitral valve repairs, whereas Surgeon B does 100 cases, of which 40% are mitral valve repairs. Should a patient choose the highest volume surgeon for their mitral valve repair procedure or a surgeon who only does that procedure? Is that important for the outcome? Although a volume-outcome association was observed, the percentage of volume–outcome relationship due to specialization was high—53% for valve replacement and an astounding 84% for performing a quality lung cancer resection. Clearly, subspecialization, or expertise, matters when looking at outcomes for specific cardiothoracic procedures in this patient population. Further support of the impact of expertise on outcomes is evidenced by examination of the 11 Dedicated Cancer Centers or Medicare Prospective Payment System (PPS)-exempt hospitals in the United States. These centers were designated or created in response to the National Cancer Act of 1971 and only treat cancer patients, with all research being cancer related. The severity-adjusted 5-year survival for lung cancer (Fig 5A) and all cancer patients (Fig 5B) treated at PPS-exempt institutions, compared with those for patients treated at National Cancer Institute–designated, US academic medical centers, and all other US hospitals, is significantly better [16Pfister D.G. Rubin D.M. Elkin E.B. et al.Risk adjusting survival outcomes in hospitals that treat patients with cancer without information on cancer stage.JAMA Oncol. 2015; 1: 1303-1310Crossref PubMed Scopus (88) Google Scholar]. These Dedicated Cancer Centers have superior survival for our children, our parents, our families, our friends, and all others who are afflicted with cancer. This, and similar examples—whether valve centers, aortic programs, or complex congenital heart programs—is what is possible when you bring experts together and ask them to bend the curve. This leads me to hypothesize that the difference in outcomes is not necessarily a volume–outcome relationship but perhaps an expertise–outcome relationship. When groups of individuals who are experts in their field come together, patient outcomes improve, and costs of care are reduced. There is real value. As I hope to have shown you, surgeons do not acquire expertise by simple practice or experience alone—it is most commonly achieved through a culture of metric-driven practice, transparency in the examination and critique of results, and a willingness to be a little uncomfortable and slightly out of one’s comfort zone. In addition, there are characteristics, habits, and practices that experts use so they can study important problems, generate new knowledge, and hopefully improve the lives of others. The results that come when experts work together and are focused on a specific cardiothoracic disease are exactly what our patients want. This is why our patients, our families, and our friends ask to see the expert.