And there's an old saying in surgery which really is true: The first 10 years when you're in practice, you really learn how to operate. I mean, you do know how to operate, but you're getting the finer details, becoming more confident. The next 10 years, you know when to operate. You manage to get the judgment on deciding when to operate in tough situations.
And the last 10 years, which is probably the most important, is you when know not to operate, because what I do, if I have to operate on somebody, I mean, sure, I can help them very much, but I could also hurt them very much.

Strategy talent: To set the stage not to perform on it

For many, having a truly great boss is the exception rather than the rule.

That's because being one takes a seriously deft touch. You have to inspire people to succeed and give them the tools they need - all while meeting company dictates. 

Most of us assess how great a boss is by how he or she manages employees.

But in order to manage employees really well, a leader actually needs to master two other things first, said Harvard Business School Professor Linda Hill, the coauthor of two leadership books, "Being the Boss" and "Collective Genius."

One, Hill said, is to develop self-awareness, to know how others feel when they're with you. Are they scared of you? Do they trust you? Do they feel you trust them?

"It's always about the emotional connection," she said. "Being scared around you doesn't lead to your being respected."

The second is to successfully manage your network of colleagues and bosses over whom you have no authority but whose support you and your team will need to excel.

Quiz: Do you have what it takes to be a great boss?

Think about it this way: Even if your employees love you, they'll become very frustrated if you're powerless to sell their ideas up the food chain.

CNNMoney asked readers to weigh in on what they think characterizes the best bosses. Three traits came up again and again in their comments.

Great leaders, they said:

1) Respect and appreciate their employees

They respect what you do, they respect your expertise and they respect the fact that you may have your own work style.

"Great bosses earn respect by giving respect," said one reader.

Bosses who say "thank you" came up a lot, too, as did bosses who publicly give credit where it's due, who welcome employees' input and feedback, and who recognize that employees are humans, not just "resources," as another reader put it.

2) Create trust and support

An excellent boss trusts you to do your job, has faith in your team, encourages your success, goes to bat for you and is always approachable.

"I would gladly follow [a wonderful boss] to another company if they left because working for them is a great experience. And you want to take on new challenges and risk because you know they have your back," said Colin Adams of Somerville, Mass.

Great bosses are also consistently ethical and fair, and they hire good people, readers said.

3) Give employees the backing and resources to do their jobs

A great boss provides clear guidance, coaching and structure but also the leeway to develop a sense ownership over your work.

Related: 6 truly rotten bosses: You know the type

And when something goes wrong, readers said, great bosses assess what happened and help you fix the situation rather than assign blame.

"[They'll] allow you to make mistakes and learn from those mistakes without throwing you under the bus," said Jim Langseth of Minnetrista, Minn.

Indeed, in her research, Hill found that people consistently said their best bosses were demanding but also extremely generous in terms of giving them the space to show their talents and giving them the benefit of the doubt when something goes wrong.

Hidden Life

“The Master doesn't try to be powerful;
thus he is truly powerful.
The ordinary man keeps reaching for power;
thus he never has enough.

The Master does nothing,
yet he leaves nothing undone.
The ordinary man is always ding things,
yet many more are left to be done.
[…]
Therefore the Master concerns himself
With the depths and not the surface,
With the fruit and not the flower.
[…]
Teaching without words,
Performing without actions:
That is the Master’s way.
[…]
The Master arrives without leaving,
Sees the light without looking,
Achieves without doing a thing.
[…]
The Master is above the people,
And no one feels oppressed.
She goes ahead of the people,
And no feels manipulated.
The whole world is grateful to her.
Because she completes with no one,
No one can complete with her.”
― Lao Tzu


cool and calm on the surface, but underneath it all is a nonstop struggle to succeed
dive deeper into your life, and discover what lies below the surface
see what is otherwise hidden
the need for such penetration of understanding
the future lies not with the predatory and the immune but with the sensitive who live dangerously
 to develop this sensitivity
the truly sensitive mind is both susceptible and penetrating: it is open to new ideas, and it seeks truth at the bottom of the well. It is the development of this sort of mind which it should be the object of the educational process to cultivate

in all education principles are more important than examples, ideas than facts, and you cannot train the sensitive and penetrating mind except by exercising it in that direction.

God can do all things

The word "Omnipotence" derives from the Latin term "Omni Potens", meaning "All-Powerful" instead of "Infinite Power" implied by its English counterpart. The term could be applied to both deities and Roman Emperors. Being the one with "All the power", it was not uncommon for nobles to attempt to prove their Emperor's "Omni Potens" to the people, by demonstrating his effectiveness at leading the Empire.

Power is influence, and perfect power is perfect influence ... power must be exercised upon something, at least if by power we mean influence, control; but the something controlled cannot be absolutely inert, since the merely passive, that which has no active tendency of its own, is nothing; yet if the something acted upon is itself partly active, then there must be some resistance, however slight, to the "absolute" power, and how can power which is resisted be absolute?

Witchdoctor. Witchart.

"Witchcraft ... takes hold in people’s lives when people are less than fully open-hearted. All wickedness is ultimately because people hate each other or are jealous or suspicious or afraid. These emotions and motivations cause people to act antisocially". The response by the populace to the kɛmamɔi is that "they valued his work and would learn the lessons he came to teach them, about social responsibility and cooperation."

...white magic...
wunderhealing

Modern interpretations[edit]

In his 2009 book, Magic and Alchemy, Robert M. Place provides a broad modern definition of both black and white magic, preferring instead to refer to them as "high magic" (white) and "low magic" (black) based primarily on intentions of the practitioner employing them.^[4] His modern definition maintains that the purpose of white magic is to "do good" or to "bring the practitioner to a higher spiritual state" of enlightenment or consciousness.^[4] He acknowledges, though, that this broader definition (of "high" and "low") suffers from prejudices as good-intentioned folk magic may be considered "low" whileceremonial magic involving expensive or exclusive components may be considered by some as "high magic", regardless of intent.^[4]

According to Place, effectively all prehistoric shamanistic magic was "helping" white magic and thus the basic essence of that magic forms the framework of modern white magic: curing illness or injury, divining the future or interpreting dreams, finding lost items, appeasing spirits, controlling weather or harvest and generating good luck or well-being.^[4]

Superpower and supreme excellence

Good fighter will be terrible in his onset, and prompt in his decision.

Agar hidup indah dan damai:

Jangan merebut hak dan milik orang lain.
Berikan hak dan kewajiban sesuai derajatnya.
Patients tell you everything.
Give the best you can do... the rest will follow

Dream high!

Your patients gives you everything you need.

The best Gurus are our patients.

When you got frustated at work because your senior complaining your work, though you had given your best, don"t worry. You'll find that your patients always with you. Giving such a various cases and treatment option. So that you can learn more. They never complain! They always on your side. 

so.. give the best respect for your patients. they are the truly gurus and mentors.

Learn from them, not only the medical aspect but also everything about this 'crazy' life.

Listen their complain, feel them, and look after them.

God will be in your side also. 

Be brave, stay calm, dont worry of anything.

Being able to own what you've done in your life is the height of class. It's not classy to play the victim, blame all your problems on someone else.

The humble poem

For the Young Doctor About to Burn Out

Professional burnout is the sum total of hundreds and thousands of tiny betrayals of purpose, each one so minute that it hardly attracts notice.

Our health depends in part on health professionals, and there is mounting evidence that many young physicians are not thriving. A recent report in the journal Academic Medicine revealed that, compared to age-matched fellow college graduates, medical students report significantly higher rates of burnout.

Specifically, they are suffering from high rates of emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment. College students choose careers in medicine because they care, because people matter to them, and because they want to make a difference. What is happening to the nearly 80,000 U.S. medical students to produce such high rates of burnout?

It is tempting to invoke the usual suspects: too many hours of study, too little contact with patients, and overwhelming anxiety concerning grades and test scores. Such stressors are compounded by exploding rates of change in medical science and technology and the general cloud of socioeconomic uncertainty hanging over the profession of medicine.

Nothing is more needed than nourishment for the imagination.

Yet the real roots of the problem go far deeper, and it is only by plumbing their full depth that we can hope to formulate an accurate diagnosis and prescribe an effective therapy. On closer inspection, burnout turns out to be a symptom of a more fundamental disorder that calls for curative—not merely symptomatic—therapy.

Nothing is more needed than nourishment for the imagination. Medical educators, learners, and those who care about the future of medicine need to understand not only the changes taking place in medicine’s external landscape but the internal transformations taking place in minds and hearts. Humanly speaking, are we enriching or impoverishing students? What alterations are we asking them, explicitly or implicitly, to make in the ways they act, think, and feel? In what ways are we bringing out the best elements in their character—courage, compassion, and wisdom—as opposed to merely exacerbating their worst impulses—envy, fear, and destructive competitiveness? 

To a minority of students who care very little about such matters, such questions are likely to seem of little moment. Such students see clearly what they want to achieve—to gain admission to medical school, to graduate, to obtain a residency training position, and to take up the practice of medicine—and they do not trouble themselves about the ways in which their education is reshaping their humanity. When such students show up in class, they simply want to know what will be on the exam, and no matter how intricate or abstruse the material might be, they learn it sufficiently well to pass—and in many cases, ace—the tests.

But there are other students for whom medical school is not simply a proving ground, a gauntlet to be run, or a ticket to a well-paying and secure career. When they see a patient treated poorly, encounter a fellow student who is struggling with confusion and discouragement, or deep in a maze of tests and grades find themselves beginning to lose sight of the goals that brought them into medicine in the first place, they do not merely knuckle down and redouble their efforts. Instead they take such matters into their hearts, muse over them, and find themselves questioning whether medicine is what they really want to do with their lives.

Where can we turn to understand what goes on in the minds and hearts of highly intelligent, genuinely compassionate young adults who find themselves in a state of moral distress about the path they have chosen in life? Who or what can help them find the words to describe what they are going through, to know that they are not alone, and to locate a light at the end of the tunnel that can give them the hope and courage necessary to carry on? To understand and help such students, we need to find and apply the best resources available. One of the best guides on the matter I have ever encountered also happens to be one of the greatest novels in the English language. 

Lydgate allows prevailing attitudes toward success to supplant his deeper sense of calling. He burns out because he loses his way.

The novel in question is Middlemarch. Written by Mary Ann Evans (1819-1880) who, in order to be taken seriously felt compelled to write under the pen name George Eliot, Middlemarch concerns the affairs of a fictitious British Midlands town of the same name. The title evokes not only a kind of provincial mediocrity but also a deep authorial concern with what happens to people training for the professions, echoing the opening of Dante’sDivine Comedy, “In the middle of life’s journey … ”

One of its principal characters is an idealistic if somewhat unreflective young physician, Dr. Tertius Lydgate, a character whose story provides deeper insights into burnout than any social science study I have encountered.

Lydgate is a handsome, well-born young physician with high aspirations as both a medical scientist and a servant of the needy. He comes to Middlemarch intending to found a charity hospital and to write a scientific treatise on typhus, one of the great scourges of the poor. Yet there is a problem. Over time, he abandons his ideals. He allows prevailing attitudes toward success to supplant his deeper sense of calling. He ends up investigating not typhus but gout, a rich man’s disease. Though outwardly successful, he comes to see himself as a failure. In short, he burns out because he loses his way. To paraphrase the novel, Middlemarch not only swallowed Lydgate whole. It assimilated him very comfortably.

Such changes can and do occur among contemporary medical students. Studies have documented both declining empathy and rising cynicism over the course of medical education. What happens? Having enrolled in medical school with a goal of helping people, students soon find financial considerations—including their own exploding debt—dominating their career plans.

Burnout is the sum of hundreds and thousands of tiny betrayals of purpose, each one so minute that it hardly attracts notice.

With a growing avalanche of new knowledge and skills bearing down on them, they feel increasingly overwhelmed by what they do not know. They soon discover that, instead of expanding their capacity to make a difference in the lives of others, the rigors of medical school have constricted their field of view to their own survival.

Burnout at its deepest level is not the result of some train wreck of examinations, long call shifts, or poor clinical evaluations. It is the sum total of hundreds and thousands of tiny betrayals of purpose, each one so minute that it hardly attracts notice. When a great ship steams across the ocean, even tiny ripples can accumulate over time, precipitating a dramatic shift in course. There are many Tertius Lydgates, male and female, inhabiting the lecture halls, laboratories, and clinics of today’s medical schools. Like latter-day Lydgates, many of them eventually find themselves expressing amazement and disgust at how far they have veered from their primary purpose.

Lydgate discovers that he has become a mouthpiece for benighted views he initially abhorred, arguing that “I must do as other men do and think what will please the world and bring in money.” Everyone needs to make compromises, but such compromises should not come at the cost of abandoning core aspirations. Quite the reverse, the primary goal should be to allow such aspirations to develop and express themselves in the challenging world of contemporary medicine. Books like Middlemarch are no panacea, but they offer precisely the imaginative nourishment so often missing from contemporary medical education, a powerful antidote to the insidious forces that produce burnout.

Johnson classification of peptic ulcer

Talent hotbed, genius factory

In a recent book, The Talent Code, by Daniel Coyle, the author discusses the nature of talent, and whether it is a matter of nature (in born) or nurture (training). More specifically presents the idea of a “talent hotbed”, by which he means those environments in which a particular type of talent or expertise has been consistently created and sustained at a high level of achievement. As examples of the concept he gives the artistic community of Florence Italy during the Renaissance, the athletic prowess of Brazilian soccer players over the last three decades, and the unparalleled apprehension of the music students at the Meadow Mount School of Music. His book seeks to answer the question of how these groups/communities are able to create such exemplary results year after year, with such speed and consistency.

The question for our purpose then is how can we create a “talent hotbed” for learning itself? How do we create a “genius factory”?

The first step to create this hot bed for genius starts with the understanding that people can and do learn in many and varied ways. Once we accept that not everyone learns the same then we must agree that in order to teach the maximum amount of people there must be a system that teaches in a way that addresses the diversity of learning preferences. We recognize that there are different learning styles, and types of intelligence, and that these must be taken into account if we are to have a system that truly succeeds in teaching “the masses”.

Of course we know that it would be virtually impossible for teachers to create daily lesson plans for each individual student, but we do believe it is possible for teaching to be presented in a manner that allows each student to access the information in the ways that are already natural to them. This can be achieved through a well-developed curriculum using a variety of whole brain teaching methodologies, in combination with the active involvement of the student in his/her own learning and assessment. The goal is to move away from the typical process, the “banking system of learning”, where the primary method of presentation is lecture oriented, and the student is merely a passive recipient or vessel, to be filled by the teacher. What is proposed instead is a more dynamic model in which the students are first taught to understand the process of learning itself, and then encouraged to explore and participate in the presentation in an active manner.

In order make this “genius factory” or “hotbed of talent” for learning we have to design a learning system that encompasses all elements of the person, from their preferred learning style to their state of mind. Too often this idea is neglected in mainstream education, and the student as a person, and their particular skills and weaknesses are seen as irrelevant. All students are taught in one way and they are expected to find a way to conform, or simply be left behind. Learning should not be a rigid passive experience, but an active and inclusive one where not only are students’ learning needs identified and met, but the learning process itself is enjoyable. When these pieces are put in place students are able to access what neuroscientists call the Alpha state. In this optimal learning state, students find it easier to excel in comprehension and memory retention, and all aspects of learning, thereby unlocking their true academic potential.

Bruce Prescod

Donovan Whylie

www.foundationsforlifelearning.org

Greatness Isn't Born. It's Grown.

The "secrets" in this book are typical of the incomplete thinking that is common to so many books on success, as explained in "Hard Facts, Dangerous Half-Truths, and Total Nonsense" by J Pfeffer.

In a nutshell, the author reveals these mundane "secrets" which also ignore the millions who start their own businesses and fail but who also follow these strategies:

SECRET 1: Financial Success Is Possible in Almost Any Field, and
Lack of Education Doesn't Have to Hold You Back.
SECRET 2: Working Hard Doesn't Mean Working All the Time.
SECRET 3: Focus on Fulfilling Your Values Rather Than Financial Gain.
SECRET 4: Loving What You Do Is Much More Important
Than What You Do.
SECRET 5: Feel the Fear. Have the Doubts. Go for It Anyway.
SECRET 6: Think in Terms of Trade-offs, Not Sacrifices, to Find a Workable Equilibrium.
SECRET 7: Sometimes You Just Have to Shrug It Off and Have a Good Laugh.
SECRET 8: Appreciate Abundance.

SIX-FIGURE TRAITS
1. A profit motive. Money per se may not be their driving force, but six-figure women absolutely expect to be well compensated for their work. They want to make money. They feel good about making money. They enjoy what money gives them. Profit, to these women, has a positive ring.
2. Audacity. Every woman I interviewed came to a point where she had to step outside her comfort zone and do something she wasn't completely sure she could do. It was rarely an experience she relished, nor did she always succeed. But she worked up the moxie to make the effort.
3. Resilience. They all had the grit to get back up and keep going when they didn't succeed or when they encountered setbacks.
4. Encouragement. Six-figure women have tremendously nurturing relationships with one or more people who believe in them, support them, continually root for them, and sometimes prod them along. Some, but definitely not all, had encouraging parents. Every one has remarkable friendships. And for those in a committed relationship, a supportive husband or partner is invariably cited as essential to their success.

STRATEGIES FOR EARNING MORE

1. Declare your intention to make good money.
2. Let go of where you are (leave your job if you feel stuck)
3. Decide which game to play - "play it safe" or "gamble to win"
4. Jump in, ready or not.
5. Keep on truckin'.
6. Grab opportunities.
7. No excuses allowed.
8. Ignore naysayers.
9. Never personalize.

Really, it's hard to believe that anyone can take this type of book seriously. This is akin to the New Age dictum that your thoughts are responsible for all your health problems and can also heal you - if you accept that, then logically you would also have to accept that your thoughts were responsible for the Grand Canyon. Two very different areas? Not really, one is just an extreme of the other.

[later note: Far better to read "Outliers: the story of success" by Malcolm Gladwell, who shows that success is complicated and is often the product of hidden advantages of culture, timing, demographics and luck. But that's probably not want you wanted to know, is it? Fine, then read "The Talent Code: Greatness Isn't Born. It's Grown. Here's How" by Daniel Coyle - at least it's research-based; also Csikszentmihalyi's now-classic "Flow" and Ericsson's "Development of Professional Expertise", perhaps the finest book written (so far) on how to generate great individual and group performances (short version: mastery takes "grit": perseverance, effort - NOT struggle but difficult, painful all-consuming effort - and passion for long-term goals).

Even later note: "The Longevity Project" by Friedman and Martin is a groundbreaking 80-year overview on what is really directly linked to success, happiness and health. Don't miss!]

Momentum...
ada kalanya perlawanan dilakukan dengan hening
ada kalanya perlawanan digerakkan dengan gegap gempita

Your Gift Is

Imagination

You are constantly dreaming. You are always thinking about what could be. You love to express yourself in many ways. You have a way with words and tell vivid stories. You love to be amused. You are good entertaining yourself, and other people find you hilarious. You're the type of person who finds staying happy easy. There's always fun to be had!

Care Philosophy

Mark D. Epstein, M.D. is committed to promoting excellence in Plastic Surgery with an emphasis in cosmetic surgery and cosmetic procedures. To treat our patients with the highest regard and respect. To utilize highly qualified staff to insure the patient care is of the highest excellence and quality that can be possible. To provide our patients with excellent care in an environment where the people of Mark D. Epstein, M.D. display teamwork, pride, honesty, loyalty and commitment to our craft. We will constantly improve the environment within our organization in order to keep our patients and staff as comfortable as possible. We are also committed to providing our Employees with a challenging, innovative, honesty and rewarding environment in which there is equal opportunity for learning and personal growth. Creativity, innovation, integrity and enjoyment are encouraged to improve the effectiveness of the Practices. By moving forward with advances in technology and with ongoing education of both the Doctors and the staff, we will become recognized as the premier plastic surgery practice in the country,

Zen and the Art of Surgery: How to Make Johnny a Surgeon

Thank you for that very generous and kind introduction.

I first want to thank a few people. My first real brush with leadership was in a parking lot in Orlando. My former boss, Bing Rikkers, was walking out of the Specialist Schools and Academies Trust (SSAT) reception in the wild animal park with my oldest son and I. Bing told me that he had a job he thought that I would enjoy. He thrust me into developing the program for this organization. He has done that for several other equally difficult, time consuming, but incredibly rewarding jobs (all of which seemed like a bit of a stretch for me). He also asked me to run our residency program which has been the source of the greatest rewards in my academic life. I will forever be grateful that he chose to come to me in Wisconsin. I hope everyone, especially the residents in the audience, can find someone like Bing that pushes you out of your comfort zone.

Second, I would like to thank Barbara Bass. Barbara, for no reason, took me under her wing. I really have no idea why she “tapped” me. There was no particular benefit to her. She introduced me to some of my closest friends and included me in events she certainly did not need to. She has been a source of advice and inspiration since the day I met her.

Last, my wife Chris who asked me not to mention that she is here. She has been there in good times and in bad, and she constantly inspires me to follow her lead and do the right thing.

So what do I talk about in a completely undefined talk? I thought initially that I would talk about research advances in gastrointestinal (GI) cancer. I then thought, maybe, I would talk about medical device development. This has both been a great scientific interest and a fun way to train students.

Bing has given some spectacular talks on leadership, which I have found really interesting. Health care reform and how to finance a surgical practice has been the focus of my academic life the last couple of years. Bing and one of my best friends, Tom Zdeblick, suggested that this should come from the heart.1 When I thought about it, the thing that I am most passionate about is training surgeons. The thing that has consistently given me the most academic pleasure is watching a resident or a new faculty member “get it”, and then succeed. The system seems to be working. Every year the people we see get smarter, but our residents do not feel competent when they finish. Five years and they are not comfortable.

Frank Lewis, the director of the American Board of Surgery (ABS), recently outlined the issues facing American surgery in the clearest terms I have seen. He acknowledged that the majority of surgical residents are seeking further training. They are doing this for many reasons, but most relevant for this discussion, many do not feel like they have the skills to independently treat surgical patients. This is reflected both in the increase in fellowship training and in the worrisome rise in the failure rate of the ABS certifying exam.2

Dr. Lewis concluded that we should consider earlier specialization in general surgery. This has already been done with great success in vascular surgery. Early specialization means that specialty training is interspersed with general surgery training, with the last 18 months or so devoted to the specialty. In vascular surgery, the first 3 years are typically devoted to general surgery, the last two to vascular. The middle year is split about evenly. There are, of course, lots of details that will need to be worked out. These issues should not stop us from pursuing this course. The other option is to leave our system alone and let the market set the training. This, to me at least, means we are evading our responsibility. I think we can do better, but we need to change the way we do business. We need to do it for our trainees and for our patients. First, why is this important?

This is Gonzalo Gasca (Fig. 1). Mr. Gasca is a patient of mine. He, unfortunately, had pancreatic cancer. Mr. Gasca was in his 70s and retired after he raised his family. He did not sit around the house after he retired, but began living to work. He was one of the guys at Wrigley Field that points you to your seats (per the HIPPA guys, I cleared this with his wife). I have trouble imagining a better job.

Fig. 1

Gonzalo Gasca

He was treated preoperatively with chemoradiation, and after a long stretch in the OR we discovered that we were going to leave the tumor behind and had to abandon the procedure. The next morning, with some trepidation, I went to talk to him. I sat down next to his bed and told him that we left the tumor and that there was not much more that we could do. His response was, “You look like this is bothering you a lot. You did your best. I know it. That's how life goes. You need to stop thinking about this or you won't be able to focus on the next guy.” He then sent me on my way. He died a couple of months later. His wife sent me a thank you note. One of the interesting things about speeches like this is that you can intersperse little parables to illustrate points like this story of Mr. Gasca.

A small boy was walking along a beach at low tide, where countless thousands of small sea creatures, having been washed up, were stranded and doomed to perish. A man watched as the boy picked up individual creatures and took them back into the water. “I can see you're being very kind,” said the watching man, “But there must be a million of them; it can't possibly make any difference.” Returning from the water's edge, the boy said, “It will for that one.”

Sometimes we lose sight that, ultimately, we are training surgeons to take care of people. Individual people like Mr. Gasca. Now, we are initially training surgeons to be good at hundreds of diseases and masters of none. We should be training them to walk out of that patient's room and know that they did their best and that their best was exactly what that patient needed.

So why did this guy trust me? I suggest it is because he thought I was an expert, not that I was the best surgeon in the world or the US or Chicago, but an expert. The first question every patient asks me is: How many of these have you done? Patients know intuitively that, though volume does not equal quality, it matters, but we are not training experts in general surgery. We are not training experts in GI surgery except in a few fellowships. We are training good and competent surgeons and hoping that these really smart people will become experts.

I would like to suggest that we need to change our focus to training experts, not good surgeons, but experts in the management of GI diseases. We need to develop experts who will get better and better over their career. As other parts of general surgery have developed their own focus, we have retained what I consider the best part and the core of surgery—the GI tract. This core of GI surgery is markedly different than GI surgery 20 years ago. The knowledge base has expanded, most GI diseases are not approached with a big incision and most of the diseases we treat are done as teams, not as individuals. We have trained really good surgeons more and more broadly. As GI surgery has become more focused on minimal access, we have had to train for twice as many procedures. We can keep doing this and let others “finish them”, or we can try to change the way we do this. So how do we deliver quality to our customer—the patient?

We are now finishing residents, competent to do a few procedures—laparoscopic cholecystectomy, hernia repair, perhaps right colectomy—but what else are they really trained to do? The world shifted while we were not watching. I know you have all heard the phrase “just a general surgeon”. We have always answered the “just a general surgeon” question with an eye roll, those guys do not understand what we do. My thought is: Those guys may be right. I am not sure, but they might be right. I propose that we need to train experts and focus on quality. I propose that we need to train experts, not just good surgeons.

Before we develop experts, we need to develop competence. Dick Bell gave a great talk at the Central Surgical last year entitled: Why Johnny Cannot Operate. I stole part of his title. He showed sobering data that of the 121 essential operations only ten were performed more than 20 times by the average resident. Eighty-three were performed less than five times. Nothing obscure here, these are essential procedures.3 Dr. Bell suggested that we rethink what it means to be competent. Many essential procedures are being performed once or not at all. How can we be competent at something we have never done?

Let me highlight the average number of cases performed by our US graduating chief residents for three GI procedures: trans-anal excision of a rectal tumor, zero; bile duct exploration, one; vagotomy, zero. The surgeons we are finishing are not competent to do these operations, but maybe performing 80 laparoscopic cholecystectomies translates into competence in other GI diseases? Overwhelmingly, the evidence is no. This is clear not just in surgery but in almost any technical field. An expert pianist is not also an expert violinist.

Maybe a bowel anastomosis, though, is a bowel anastomosis, but a colectomy and an esophagectomy are not just anastomoses. If you have never done a sigmoid colectomy, no number of esophagectomies is going to teach you how to avoid injury to the ureter.

Experts tend to see patterns that become more complex as they develop expertise. They recognize when something does not fit this pattern. An expert surgeon knows when something is wrong. They, perhaps, cannot verbalize it, but the pattern is wrong. They recognize that they need to slow down when something is not right.4 The answer, thus, is NO. Eighty laparoscopic cholecystectomies do generate expertise for laparoscopic cholecystectomies but not for colon resection. So, we are not really training surgeons for competence in the breath of GI diseases.

Can I take this argument a step further and suggest we develop experts in a smaller piece of surgery? But, and this is a big but, to become an expert requires 10,000 h of deliberate practice over an extended period of time.5 It does not matter what task you pick—sports, music, chess. Ten thousand hours in one thing. Ten thousand hours of violin practice, not music practice. Does 10,000 h managing pancreatic cancer make one an expert in the management of rectal cancer? Our “general surgery” paradigm says yes. The public, the residents, and the data on survival of patients with GI cancer and surgical groups and academic departments say no.

So what is deliberate practice? It has three components—it must be beyond your current level of performance, there must be feedback, and you must be doing it not because you are required, but for its own reward.

It is easy to imagine feedback in surgery—anastomoses leak, patients die, during our training, the experts critique our performance. In chess, a grand master typically spends 4 h a day evaluating the moves of experts in other matches. An expert pianist practices alone, 4 h per day. An athlete competes with other elite athletes, but how does all this apply to the development of expert surgeons? Can we train an expert or even a competent general surgeon in our current 5-year training programs? Do our residents really spend 4 h a day in deliberate practice? At that rate, it will take 10 years for them to become an expert, but, and this is another big but, they need to continue deliberate practice for longer than we are training them. Anders Ericsson has written extensively on this topic. He presents many examples from medicine, all with basically the same outcome. Residents are better than medical students at almost any task tested, for instance, detecting an abnormality in heart sounds. Cardiologists are better still. After 10 years in practice, cardiologists remain just as good. The general practitioner, however, is not as good as the medical student (Fig. 2).

Fig. 2

Ericsson, K.A. (2004) Deliberate Practice and the Acquisition and Maintenance of Expert Performance in Medicine and Related Domains. Academic Medicine 79(10): S70-S81

I propose that, to develop expertise, the focus has to be narrower than general surgery and maybe more narrow than GI surgery. This can obviously be taken to an extreme, experts in only right colon diverticulitis or something equally ridiculous. Broadly trained GI surgeons able to deal with GI emergencies and trauma are essential. We also need broadly trained surgeons to deal with access to care in the rural parts of the US. There will clearly be other paths to competence in general surgery—critical care, rural surgery, trauma, surgical oncology, etc.

I serve on the GI surgery advisory committee of the American Board of Surgery led by Ken Sharp which has taken on the task of restructuring GI surgery. Though I do not speak for the board, what I propose has broad support, and a consensus for GI surgery has developed.

If we took this broadly trained GI surgeon after 3 or 4 years and then focused their training in either colorectal disease, pancreatic/biliary/hepatic disease or foregut disease, these expert surgeons could deal with almost any GI emergency and be an expert in colorectal, pancreatic/biliary/hepatic, or foregut surgery.

I suggest that we change the way we train GI surgeons. Dick Bell suggested that we change the standards for case experience, improve operating room (OR) teaching and make operative skill a required competency. That is obviously a great start. I would move a bit beyond that and make three other recommendations for training GI surgeons.

1. Focus the first 4 years of surgical training on the development of broad competency in GI surgery. Then, focus 2 years of training on either HBP, foregut, or colorectal surgery. This will change residency training. Not every program could do everything, and some residents would need to move to obtain these last 2 years of training, but they are already moving to do fellowships, so this just makes it more formal.
2. Expand training to 6 years. The last year must be one of independence. Our residents are already training 6 or 7 years. This would assure both expertise and independence.
3. Forget about being “just a general surgeon”, and instead, become an advanced GI surgeon. Advanced GI surgery must become synonymous with quality, not basic competence.

So why go there? Our trainees have adapted to our current system and are almost all selecting more training. The SCORE project of the ABS has defined a terrific curriculum for our residents. Nothing is broken. Our outcomes are the envy of the world. Our training attracts the best of the world. I suggest that we need to alter the training paradigm, mostly for the patients, but also for our trainees.

The Zen in my title: “Zen and the art of surgical training” is why we need to train expert surgeons. So that they are effortless experts and that effortless expertise generates happiness and contentment in our surgical workforce. Effortlessness is the essence of Zen.6

Another parable (from David Foster Wallace): There are these two young fish swimming along and they happen to meet an older fish swimming the other way who nods at them and says “Morning, boys. How's the water?”, and the two young fish swim on for a bit, and then eventually one of them looks over at the other and says “What the hell is water?”6

I am not claiming to be the wise older fish mostly because I am not wise, but I also have this illusion that I am not getting older. The point is that, sometimes, what is the most obvious is the hardest to see. I could be speaking about the obvious conclusion that if you need 10,000 h of deliberate practice to be an expert, we are not even close to delivering it or maybe that everyone does not need to be an expert. I suspect, though, that the people in this room are either experts or want to be or they would not waste their time traveling to DDW. I am suggesting that sometimes the obvious realities are the hardest to see and for sure the hardest to discuss. So that is what I would like to finish with.

I want to speak directly to the residents and fellows and those just starting down this path. The real value of your surgical training (I am paraphrasing David Foster Wallace again here) is how to avoid becoming a comfortable, respectable, well-compensated, two-house, three-car, unhappy surgeon working endlessly at their job. The older people in the audience perhaps understand that there is a reason they call it work.

You get in your car and start driving to work, some moron in a Hummer cuts you off while talking on a cell phone, the attending anesthesiologist has refused to see your patient because the midline incision is not marked, the OR takes 2 h to turn over because the cleaning crew is short, this means you miss the soccer game for the fourth straight time. You guys are not there yet, but you will be.

Your default is: I cannot believe these overweight lazy brain-dead people are keeping me from doing what I want to do. Your default is—it is about me. It is easy to treat a nurse as if she (still overwhelmingly) is your servant. It is easy to treat the guys that clean the OR rooms like they do not exist or I can force—and I really mean force—myself to think that the cleaning crew is understaffed because one of the crew's kids was sick and the day care would not take him or the Hummer driver is taking his kid to the emergency room (ER) or the nurse has something to offer in the care of your patient.

Maybe you should listen. Listen to scrub technicians and nurses, listen to the residents, listen to your friends, and listen to yourself. Perhaps their lives are more tedious and boring than yours. It is possible, maybe not true, but possible. It takes effort to consider this, but you get to decide. You get to decide if you will pay attention, you get to decide who you will listen to, and you get to decide what has meaning. Let me illustrate with another parable from Kamala Masters.

A Buddhist practitioner went to visit her teacher. He was 84 and she was taking him to visit Buddhist sacred sites. At one point, they were in a train station. It was blazing hot. The train was 5 h late. There were no restrooms. They had no food. The station agents kept changing the track, so they had to keep getting up and moving. The student started to worry about how her teacher was holding up since she and her friends were barely coping, and he looked so frail. Finally, she decided to ask him if he was all right and he replied, “There is heat here, but I am not hot. There is hunger here, but I am not hungry. There is irritation here, but I am not irritated.”7

Let us go back to surgery. There is confusion here, but I am not confused. There is anger here, but I am not angry. There is irritation here, but I am not irritated. Only the surgeon can bring order from chaos and confusion in the OR. When a surgeon becomes confused, unsure what to do, irritated or angry, the system tends to fail and the danger of a bad outcome rises.

The real value of surgical education is the freedom that comes with self awareness and the flow that happens during a great surgical procedure. This means focusing completely and totally on the patient.

The alternative is a focus on something that will fade—beauty, intellect, wealth, even personal freedom. None of this has anything to do with how smart you are, though we have already selected you for that. It has to do with staying completely in the moment. This is the essence of Zen. If your mind is ready and focused, it is open to everything. If you are thinking about what happened yesterday or what you need to do tonight, there are few possibilities.

The beauty of surgery is that we have the means to get to that place every day. We just need to be in the OR; we need to be with our patients. “It's the water”, but being in the OR does not mean standing around checking text messages or answering pages, it means being totally engaged.

A great book called Flow proposed that there were three professions in which flow was an intrinsic part of the job, professional dancing, rock climbing, and surgery. Not medicine in general, but surgery. The author Mihaly Csikszentmihalyi interviewed many creative people, and they all described the same experience (Fig. 3).8 A reality that was different from everyday life. A pianist described it as a state of ecstasy in which the music seemed to flow out of his hands as if his hands moved by themselves. Ecstasy is a Greek word that actually means standing to the side. A poet described it as opening a door and floating through. It is not something he could force, and most of the forces were trying to keep him from opening the door.

Fig. 3

Mihaly Csikszentmihalyi Flow: The psychology of optimal experience Harper 1991

The mystical part of this is that the author concludes that this is the path to true happiness. Furthermore, that this is not something that is confined to smart people or artists, but that it is available to everyone, but—and of course there is no free lunch—that is why they call it work. It takes 10,000 h of deliberate practice over 10 years to get there. Let me try for a minute to describe what he considered flow and apply it to surgery:

First, there must be total concentration with clarity of the task before you.

You must have the ability to look at a surgical problem and know what to do, the complex pattern recognition needed to know where everything is or might be.

There must be a feeling of being totally present and totally in the moment.

Even though it is a stretch of your ability, you must have the feeling that you have the skills to do the task. We are back to that 10,000 h.

As things become more complex, a feeling of serenity, effortlessness, and clarity should become more noticeable, and finally

Timelessness: that star wars coming out of hyperspace feeling after a particularly complex procedure, realizing that hours passed in what seemed to be a moment.

I suggest that you have all felt it doing something. You have felt total engagement in which you are not aware of time passing. The slowing down of an operation or a sport when it is the most dangerous. You have a feeling that your hands are just doing something and when you think about how your hands do it you lose that feeling. The feeling that your mind is not concerned with anything but what you are doing right now.

We have the ability to achieve this every day in the OR. The trick is to get there, to stay there, and to apply it to the rest of what we do; apply it to the real world of traffic and Hummers.

So this is all very esoteric and interesting, but what does it have to do with GI surgery? The system we have set up is to broadly train a minimally competent surgeon who can hopefully get more training by others and become experts.

It comes back to the fish. Why did every one of us pick surgery—not because it is easy, not because it makes us rich, but because we thought it was cool. I vividly remember watching R. Scott Jones removing a bile duct cancer when I had no real idea what a bile duct was. It was effortless without a wasted motion. That was why I wanted to be a surgeon.

We need to focus completely on developing the skills that made us want to do this in the first place. The problem is that a trainee does not typically have the adequate skills to develop this ecstasy of stepping off to the side. If you are worried about the 200 steps of a Whipple procedure you cannot develop flow, same deal with a colostomy or anything.

You get back to that pesky 10,000 h and the need for deliberate practice for its own reward because clearly you can do a procedure without flow and do a good job. The commitment to get to this level needs to be that of the violinist practicing 4 h a day for 10 years. My proposal is that it is worth it and that we should focus within our training programs to help our trainees become experts. That is how to make Johnny a surgeon. Not through curriculum, not by decreasing what we expect of them. We can make Johnny or Joannie (sorry) a surgeon by narrowing their GI focus and giving them the means to develop flow. That means deliberate practice outside their comfort zone. It means independence in the OR and in the ER. It means getting back to attracting people that want to do surgery because it is just the coolest thing in the entire world. We want those guys and gals, and we must not ever turn them off.

So my advice to the younger surgeons: Commit yourself to becoming an expert in something. Prioritize your time, and do what makes you happy. Please do not think of this as an assault on work hours. I totally support them. The first thing I tell new young faculty is to take up golf, and never ever skip a family vacation. How do you not miss that soccer game? By not planning something that you know deep down will conflict with it. Multitasking does not work.

When you are “at work” and training is not school, it is work. Watch, without distraction, someone that seems to have flow. You know who they are. Get out of the library or the cafeteria and watch people do surgery, watch them talk to patients. You did not dedicate all this time to training to not drink from it at every opportunity.

Know a disease so well that you do not have to think to know what to do. Know an operation so well that you anticipate what will happen. Know a patient so well that you know what they would want, and when you are not in the OR, focus on true happiness. Find people that make you happy and hang with them.

My mother died last October. I do not bring this up for sympathy. She developed unresectable lung cancer and was 83. She focused her life on having a gin and tonic with my wife Chris every night. Only I could make it appropriately. That hour every day with the two women of my life was a special gift. You will never know where that gift will be lurking unless you stop a bit and listen.

I am convinced that we need to change the way we make Johnny a surgeon. Our focus must shift to developing expert GI surgeons focused on specific GI diseases. We need to focus on the Zen of this wonderful thing we call surgery. It is the water that makes this all worthwhile. It is why we all chose to do this. It will bring us nothing but happiness and satisfaction. That is how to make Johnny a surgeon.

This is truly the pinnacle of my career. It is a pleasure to share this day with my closest friends. I feel like I have grown up as a surgeon in this society and thank the SSAT for this privilege.

A final parable:

A lecturer at a university is giving a pre-exam lecture on time management. On his desk is a bag of sand, a bag of pebbles, some big rocks and a bucket. He asks for a volunteer to put all three grades of stone into the bucket, and a keen student duly steps up to carry out the task, starting with the sand, then the pebbles, then the rocks, which do not all fit in the bucket.

“The is an analogy of poor time management,” trills the lecturer, “If you'd have put the rocks in first, then the pebbles, then the sand, all three would have fit. This is much like time management, in that by completing your biggest tasks first, you leave room to complete your medium tasks, then your smaller ones. By completing your smallest tasks first you spend so much time on them you leave yourself unable to complete either medium or large tasks satisfactorily. Let me show you.”, and the lecturer re-fills the bucket, big rocks first, then pebbles, then sand, shaking the bucket between each so that everything fits.

“But Sir,” says one student, slouched at the back of the theater, “You've forgotten one thing.” at which the student approaches the bucket, produces a can of beer, opens it and pours into the bucket. “No matter how busy you are,” quips the student with a smile, “There's always time for a quick beer.”

Thank you again for this great honor.

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