Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hello, good evening. Good afternoon. Good day. Good morning, wherever you are in the world and welcome to the Black Belt Academy of Surgical Skills. My name is David Regan. I'm a cardiac surgeon in Yorkshire and the past director of the Faculty of Surgical Trainers for the Royal College of Surgeons of Edinburgh and a visiting professor at Imperial College, London. I'd like to thank you the followers 3294 on Facebook and 531 on Instagram across 77 countries. If you're returning, thank you. And if this is your first time, have we got a treat in store for you? Because it's my privilege and pleasure to introduce Professor Roger knee bone. Now Roger first trained as a general and trauma surgeon working both in the UK and in South Africa. But after finishing his specialist training, he decided to become a general practitioner in, in practice in Trowbridge, Wiltshire. And in the 19 nineties, he pioneered an in in innovative national program of minor surgery within primary care using simulation and computer based learning programs. And he left that in 2003 and is now the professor of surgical education at Imperial College. He's one of the foremost experts on expertise and has expanded the thinking of Ericsson's 10,000 Hours. He directs the Imperial College Center for Engagement and Simulation Science based in the Division of Surgery at the Chelsea Westminster Hospital in London. And his code with his co director, Professor Fernando Bello leads a multidisciplinary team whose aim is to advance human health through simulation, collaborating closely with clinicians, scientists, patient's the public and experts outside medicine. In fact, he's committed to education in its wider sense. And in 2011 became the first Imperial academic to receive a Higher Education Academy National Teaching Fellowship Award and established the Masters in Surgical Education Program at Imperial College. But he also works with the Royal College of Music. And this collaboration launched in 2016 explores the challenges of performance across the domains of all the arts. And he's researched the experts in magic puppetry, embroidery, cooking illustration, percussion, and combat, flying. In recognition for his innovative work. Roger has been awarded the honorary membership of the Royal College of Music and became the first honorary fellow, the city of Guild of the London Art School. And in January 2009, Roger was elected Professor of Anatomy at the Royal Academy of Arts, the 14th person to hold this post since William Hunter were extremely privileged and pleased to have Rodger with us this evening. And I'll put a plug in for his book on the expert. We have the world's expert with us today to talk about this. Welcome, Roger. Well, thank you very much, Roger. I know you are an expert. How do you define an expert? Well, I'm, I'm not sure as I am actually. And I think that that that really goes to the heart of, of your, your question. I think it can be very difficult to define an expert. I think experts are easier to recognize than they are to define in a way. Um And I think, I think a clue often comes in how they describe their work. Um And I, I start my, my, my book with an example of a, of an expert outside the world of medicine. Completely Derek Frampton who's a taxidermist. Um And I described my experiences going to see him in his studio. He's a, he's been a taxi hemisphere, I think 45 years, something like that. And when I saw him, he was um he was just putting, just putting the final touches to a very beautiful life like clouded leopard. She was, she was sitting on a plinth and she had a tiny cub in front of her and she looked so life like it was really very difficult to believe that she wasn't really in a way. And I mean, in a way she was really, you know, it was a really clouded leopard who had been, had been prepared. And I asked him how he did it. And his reply gave me a clue, I think into, into what being expertise because he said something like this. He said, well, it's very straightforward. Ready Roger, what all you do is a creature like this is you um first of all, you take off its skin and then you prepare it, of course to make it subtle and things and then you just um you just sculpt a clouded leopard that size and shape and you put the skin back on. And uh to me his use of that word, just you just sculpt a clouded leopard that size and shape and put the skin back on said spoke volumes because to me it, it's sort of encapsulated the way he was able to describe work that for anybody else would be unimaginably challenging. I mean, you know, beyond, I can't imagine sculpting any, any leopard, let alone a clouded leopard, let alone one exactly that 1000 check. And so, so that, that, that way of talking about your work, which which combines a sort of pride in its recognition and a pride in its quality, but a humility that goes alongside it, I think really, really sort of summarizes what it is to be expert because I think you only do that after you've gone through a lot of preliminary stages. One of which is knowing nothing about it. The next one of which is knowing so much about it that you want to boast about it. And then finally that stage where you know so much about it that you no longer want to boast about it and you're thinking more about how far you still got to go, then how far you've come. And, and although it's not an infallible guide, I think that that way of talking about your work gives a clue to the, to the process that somebody has gone through in order to become what we would call expert, even if they themselves don't feel comfortable with that. Two. Um So that's a, that's a long answer to a short question, David, but it's, uh you know, something I've been struggling with all along is how, how you do define an expert. And I think very often it defies a simple definition, but it is something that once you get your eye in, you can often recognize. I love the way you've introduced humility into the answer because we have talked about that before in the Black Belt Academy. But you were a surgeon, yourself, a trauma surgeon and you, we're an expert as surgeon as well. How, how then how then do you become an expert? Well, I'm not sure that I was an expert in that sense. I mean, I was a competent trauma surgeon by the time I became a consultant and things. But really, I was just at the beginning of what would otherwise have been a lifelong career as a surgeon except that I changed direction and did something else and then went through that process again when I became a GP. And, and after being a GP for almost 20 years, I think I got to the stage that I got to as a surgeon of beginning to get a sense of what it was about becoming comfortable with some of the things that had been a big problem to begin with. But, but still recognizing that I was, I felt at a fairly early stage myself, although I was beginning to get to the point where I could support other people and, and share some of the things I'd learned along the way with, with other people who were, who were sort of following that path. And I think that that is a characteristic of becoming expert. And I think, I think becoming expert is a, it's a process of becoming, it's a, it's a, it's a pathway rather than a destination. I don't think you ever get there. I think you can say when people are not expert. Um and maybe you can, you, you can make judgments about when you think or to what extent you think they are expert. But I think it's really hard to make that judgment about yourself. Uh What is your experience observing other experts? I know in your book, you talk about Taylor's and Puppeteers, you mentioned the taxidermist. What are your observations and learning from them? Well, I think my I mean, I spent a lot of time working with people who I consider to be expert, whether they do or not. Um, and so these are people who, who have almost always been doing what they're doing for a very long time, have spent a lot of time focusing on it. A lot of effort, um, and have become extremely good at what they do and what I tried to do over the, you know, I don't know, 2030 years I've been doing this, which comes really from a fascination in, in, in, in what we're finding out more about what highly skilled people do in areas that I know very little about to begin with. Often nothing about was to try and put, try and put all those experiences together and draw out what I thought would be, what I hoped would be helpful principles really of what that pathway towards becoming expert might look like if you sort of tried to float above individual instances and pull out more general principles. And, and so what I, what I did in this book was too, was too use a model that people in the western world particularly are very familiar with it. The sort of well established medieval guild model of a three stage procedure where you start off as an apprentice for many years working in somebody else's traditionally in somebody else's workshop, doing what they tell you and, and, and really just, just doing what you're told. And then, and then reaching the stage where you can, where you take up your indenture as you go out, you, you become a journeyman as it used to be called a journey across your country, making a living out of the skills that you've learnt in that workshop. And then finally get to the stage after many, many years where you can set up your own workshop and you become um astor and you have Prentice's of your own. And the, and so the wheel continues to turn. And of course, these days, we no longer use those terms in any gendered sense. I think that's important to point out. But the, the, the idea of a sort of stage as a series of stages, I think it's very familiar, particularly in, in, in the, in the west. But I think one of the, and so that's one of the, one of the attractions of that model is that it's, it's well known and familiar. One of the limitations of those that model though I think is that it is a descriptive account rather than an explanatory account. And it describes what that process looks like from the outside, but it doesn't really tell you what it feels like from the inside. And so so in the book, I've tried to pull together different three different strands. One is one is a general awareness of what other people have written what's out there in the literature of course, you know, you mentioned Derricks and we'll talk about some of these ideas. I'm sure one of them, another. The second of them was to try and piece together from other people I'd seen and worked with and continue to work with their accounts of different stages in that pathway. And then the third one I wanted really to get at somebody's inside story of, of what that was like. And of course, the only person who's inside story I have direct access to is my own. And so that's why I've included elements of my own experience professionally. Um in terms of, you know, the different stages, you've mentioned training as a surgeon, then becoming a GP and then becoming an academic um in order to get access to, to some of the if you like the emotional experiences and the, you know, the ups and downs and the what it felt like to go through these stages that I've talked to other people about and read about. But of course, uh mine is the only experience I can access directly. And so that's what I tried to do was too, was to highlight what are key aspects of that learning in somebody else's space, doing it yourself independently, relatively independently and then passing your, your wisdom and knowledge on. Um And I wanted to draw out more general principles and I wanted to highlight things that I hadn't read about or heard about or things that I thought other people would find useful to know about. And we can talk about some of those in a minute if you like. And alongside that, pull out some of the things that are often not talked about or not acknowledged. And one of them is the inevitability of error uh in it's many forms. And the other, I think it's very important is the, is the ability to improvise uh and what that means in, in, in any area of expert practice, but particularly in this context, in a clinical sense. Um and to try and see how these, these things that do not run in exact in lockstep with the stages that you're going through in terms of how many years you've spent doing one part or another part of the pathway or training because where error is concerned, you, you just don't know when it's going to happen and you don't know what age in your directory you're going to be at when it does, you do know for certain that it will but you don't know how and when and so I think there's something very, there's something very interesting about, about what stage people have reached in their personal development. When these things happen from, from your own career in surgery. Rodgers. Can you come back and talk us through some of those emotions and feelings you had from your apprentice to genuine too your stage or mastery and surgery. Can you pull out some of those for us. Yeah. Well, I've used some of them as a, as a sort of a starting point for identifying what I think as key, key points of transition, if you like key points and kind of tested those out with, with these 25 or so other experts, mostly outside medicine completely to see if they made sense in a lot of them did. And the first one, so the first stage, the apprentice stage, I talk about doing time. I talk about that experience both as in my case, both as a medical student and as a trainee surgeon of, of having to spend a lot of time doing stuff that needs to be done or that other people tell you to do. But that at the time you don't really enjoy and sometimes find really boring. Uh and can't see why you're having to do it. Uh And why somebody else couldn't do it instead. Uh And so as a medical student, it might be, you know, taking blood or writing out loads and things and for all sorts of as a surgical trainee, as I'm sure many of the surgeons watching will be familiar with hanging onto retractors. I mean, certainly when I was doing my training, it was before keyhole surgery. So I wasn't holding camera, but I was holding a retractor very often one end of a retractor who's other end I couldn't see on the other side of the operating table from the main surgeon and just standing for hours and hours in a crippling the uncomfortable position doing something that I thought somebody else would actually be better off doing. Some people would say that would not be constructive learning time. No, they wouldn't. Absolutely. And, and that's, that's one of the really interesting things about, about looking at that stage, I think because the view at the time and the view in retrospect are very different, I think. And, and I talked to a lot of people, uh one person, particularly Joshua Bernard Bespoke Tailor whose ideas of influenced me a lot. Another stone carvers, uh Paul Jackman, various people who've spent a lot of time in their apprenticeships doing boring, repetitive things in no apparent value at the time. But they did pick up on the Josh story because I like the Josh story because he spent ages making pockets. Yeah, Joshua elaborate on that because yeah, pockets, pockets, pockets. He this is pocket flaps where the sort of so Joshua Joshua Burn only decided fairly late on. Well, he was at university studying economics and agriculture when he suddenly decided that actually he didn't want to do that, he wanted to become a tailor. So he dropped out of university and became an apprentice Taylor, an apprentice making jacket making Taylor. He did two apprenticeships. In fact, one is making Taylor one as a cutting Taylor took him years. But when he was an apprentice jacket making Taylor. He said it was very frustrating because he could, he could, he could see very quickly what it was he needed to do. But it was years before he was actually able to do it. And his example was pocket flaps and pocket flaps on jacket have to be very carefully made. They're much more complicated than you look than they look. And they have to, they have to conform to the shape of the jacket. They mustn't flap open, they mustn't bunch up. They, you know, they're much more difficult than they look. And so for, for weeks and months, he was at his desk, um, at his bench in his master's workshop, very traditional making pocket flaps, sewing them, putting in lining, sewing. And every now and again, his master's would just come along and look down his nose and say no, no good and go away again. And he wouldn't tell him why it was no good, but he told him it was no good. So he just had to keep on making these, these pocket flats. And he said it drove, drove him spare with, with boredom and frustration and it was awful. He said, but in the end, he learned how to make pocket flaps. And that's what he thought the nature of the task was that the jackets needed pocket flaps and he was there to make jackets. So he was making the pocket flap in retrospect though, he said, and when he started to talk to me about it. He, he said the penny dropped that actually he learned all sorts of things. He didn't realize he was learning at the time. One of them in doing all that boring repetitive work was learning how to cope with doing boring repetitive work because every kind of work that is worth doing has boring repetitive components. And if you, if you can't hack it with those, you should be doing something else because they are just part of the job there. It is. But the other thing is that he, he said he learned all kinds of other things as well in retrospect, because in making these pocket flaps for many different kinds of jackets and many different kinds of linings, he was gaining sort of deep understanding of the materiality of cloth and thread and needles and what, what was the difference between this kind of tweed and that kind of tweed or velvet or silk or uh, linen or whatever? Uh And what did the different kinds of thread feel like as they went through? What the different kinds of needles and all that kind of thing? What did it feel like to stitch different ways? And, and so it was through doing the pocket flaps that he learned a lot of that and he internalized it. And by the time he got to the stage of being able to do pocket flaps, um to the requisite standard, he'd done it so many times that this had become automatic and he'd also learned what it was to sit next to other people who were getting bored stiff by having to do things they didn't really want to do and feeling pissed off because they're masterchef around and wouldn't tell them what was wrong but just told them it wouldn't do and all that kind of thing. And so there was something about becoming a member of a group, uh and share ing an experience that made a lot of sense to me thinking back at my days as a, as a, you know, junior doctor and then as a surgical registrar, all that kind of thing, um where very often there was sort of camaraderie and having to do stuff that nobody particularly wanted to do because it wasn't glamorous, but the work required it and the professionalism of the work required that you did it and shut up and didn't moan. Um And there's, there's something about a bit of a leap of faith that you have to grit your teeth and do that. I think very often because you don't realize at the time that it will turn out in retrospect to have had these benefits or it may do. Um that that was, and I think that's something I, you know, all the experts pretty much that I've talked about have been through some phase like that. That, that to me when you're talking about materiality is the sense of feel of the material. In the same way the a surgeon would get a feel for tissue. And I know in your book you talk about opening up an inflammatory abdomen with inflammatory bowel. Yeah, are not having any tissue planes, but you had that sense of feel. Yeah, that was, that was, that was an experience. I mean, if this was in Barrow gonna hospital in Soweto, a lot of people have been stabbed and shops and things, but sometimes they were ill to and this was somebody who had uh well, no, actually this is somebody who had, who had typhoid uh and, and um typhoid affecting this morning test in. And that was a real, that was a real, I, I don't know for me because a lot of the work that I had done until then was young, young, young men, largely who had been stabbed or shot and, and we're otherwise healthy and so their, their intestines felt pretty, sort of pretty healthy. Uh And all of a sudden here was somebody who's, it was just like wet blotting paper. It was horrible. And I mean, obviously all experienced surgeons have experienced that kind of thing. David, I'm sure you get it with sort of very diseased heart valves and things that either incredibly hard or incredibly soft. And you, you know, you, you have to reconfigure, don't you, how you, how you approach it? Because the normal techniques that you've learned don't work stitches pull out or they won't go through or whatever. And it really brought it home to me how, how complex is that relationship between different people's insides, uh, different on different occasions and, and in different conditions and how that meets with your own ability to cope with the unexpected and to come up with appropriate solutions to things that you may not have encountered before. So there's materiality then, yeah, it can, can only be gained by doing lots of it. Then we'll I think lots of pockets. Yeah, lots of pockets. I think so. Um And that makes sense, doesn't it? Because I mean, you're not going to get necessarily or be allowed to work on a really difficult one from the beginning. And I mean, you know, one of the, you mentioned a textile artist, I've, I've been working with FluoroCore who spent a couple of years as the embroidery er in residents in vascular. So one of the vascular surgery units at ST Mary's led by my colleague, Colin Big Knot is a consultant vascular surgery. And that was very interesting because she was um you know, she was, she was observing vascular surgery and she made very interesting comparisons between, you know, patient's with, with very difficult uh atheromatosis or inflamed or, you know, difficult blood vessels and the work that she was doing with uh with, with working with, with historic textiles, you know, with Victorian or earlier textiles that were perhaps beginning to disintegrate or, you know, had to, had to treat them with great delicacy. Otherwise, she would make a bad situation worse and they could easily ripple or fall to bits or fragment. And so, although she hadn't and was never, of course, being nonmedical able to do the things that vascular surgeons were doing, she could understand similar challenges in, in working with materials that were delicate and at risk of, of, of collapse or disintegration um that were valuable, often priceless as, as indeed, of course applies to our patient's and which require a different set of sensitivities. From those you get from an orthodox early stage training in healthy, normal, straightforward examples of what you will later encounter in a very different form. But you do have to appreciate in the end as you embroider did and you did with the typhoid abdomen, a sense of feel and materiality. I think it is a lot of it is a sense of feel, isn't it? And it's very hard to put into words and therefore it is one of those things that really slips away from written accounts. Yes. Uh And it slips away from anything that isn't you feeling it? So you can get a sense from a video or from watching somebody else of what it looks like when they feel it. But you can't get a sense of what it feels like when they feel it unless you feel it. Mm hmm. Um uh And of course, in most, in most areas of expert of professional practice, you are not enabled nor should you be to be actually doing things that are potentially harmful to things that are especially vulnerable. You know, you don't start off when you're beginning to assist in theater as a medical student in being let loose on somebody's, you know, time for small intestine or really difficult heart valves or whatever. And so, so you, you really do have to stick with it. And that's one of the things I think that you were talking about, you know, how do you know if somebody's expert? I think you can, it may be, it may not be easy to say when somebody is an expert, but I think it is easier to say when they are not an expert and they are most definitely not an expert if they haven't spent very long doing it. So we've talked about touch and feel. But in your book, you also talk about immersion and using all your senses. You have come across other disciplines in your research where people are using senses outside of what they're feeling in tact. Our. Does that make you more of an, an expert because you can use those senses and how would you actually practice them and learn them? How do you, how do you become expert in this immersion you described? Well, I think, I mean, we're all of us using our senses, all the time, whatever we're doing, aren't we? But I think we can, I think we can sort of place more attention on some of them than others. And maybe the ones that we are invited to focus on to begin with, obviously sight and sound, you know, the ones that are easier that are more familiar and, and are seen as, as, as maybe dominance, not, well, as well as they are dominant, don't they? Really? And you know, people point things out to you. If you, let's say in a medical example, you're, you're watching an operation, a surgeon will point out things to you or they may even uh draw your attention to what something sounds like. Uh And in clinical practice is a lot of stuff about what things sound like as well as what they look like. Isn't there what they, what they smell like and, and things um least of all, perhaps what they taste like, but certainly what they smell like is much less, it's much less talked about. Um And yet experienced clinicians won't they, they will pick up all those things with the patient, say, not necessarily an operating theater, but in a consultation and they will, they will, whether consciously or not, they will register a whole lot of a whole lot of sensory cues in their environment that will then help them put all that together when they become very experienced to make sense of what the issue is. Um And I think people are more receptive. I think, I think a lot of this stuff happens below people's radar. You know, and you often, you would know, I would notice in the operating theater, you know, if there was an unexpected smell or something, you know, you would wonder whether the anesthetic tubes have become disconnected or the, you know, who knows what it was or you would immediately get a sense that there was parcel that there were feces people contamination or something like that in, in the air. And that would immediately alert you to a whole another set of possibilities or a whole another set of things to exclude or look out for. Um And I remember talking to one of the stone carvers I've been working with who teaches at the city in the fields of London Art School that you mentioned, who says that in the city and Guilds of London Art School, which is in Kennington in Central London. This is where the the very expert postgraduate stone carvers who are learning historic stone carving, you know, to replace statues on medieval cathedrals, that kind of thing. And they have a three year postgraduate course and the the practice rooms where they work are arranged sequentially 123. And the tutor said to me that she can here when a student in the third room, the furthest room away is about to fracture the carving they've been working on from the sound of the hammer and the chisel from three rooms away because she is so finally attuned to what stone carving sounds like as well as what it feels like and what it looks like when you're, when you're there with the statue you're working on. And so that sort of hyper awareness of sensory cues, I think is something that is a hallmark of, of big expert in particularly when it comes to that stage, that final stage of when you are trying to share your, your knowledge and your skills, certainly. But but also your wisdom, if you like, you know, the decision of when in surgical terms, you know, knowing when not to operate as well as when to operate. All those crucially important things that involve a very, very different kind of judgment from the ability to do a particular procedure. But that bigger decision of, of when, when to do it, when not to do it, I think comes much later on, doesn't it? A lot of this seems to be roger sort of tacit to the experienced surgeon. But as you've already alluded to fade, little is made explicit uh in, in, in the involvement of the teaching of uh the craft of surgery because it is a craft, isn't it? It absolutely is a craft. Well, I mean, it has a very strong, I think it has, it has all sorts of dimensions, all sorts of elements, doesn't it? But there is a very strong craft element to it. I think there are many kinds of craft. I think there is a different kind of craft if you like to call it that which is working out with the patient, what the problem is, uh knowing enough about it to select the most appropriate possible approaches and then choosing the best one in conjunction with the patient. And then of course, looking after patient's postoperatively, all that kind of thing, I think that that also requires very high levels of, of craftsmanship in a sense, which also requires many years of sort of steeping in uh in doing and, and being able to pick up, you know, early signs of things not being right or being not what you expect. But I think in terms of the, if we're talking about operative operative work, then yes, absolutely. It is, it is a craft and there it has strong parallels of what you would find in a silversmiths workshop or stone carver studio or indeed um in the rehearsal rooms of a music conservatoire. And that comes back to this vaccine question of doing time and Erickson's 10,000 hours, how do we reconcile the problem of we had European working time directive. Uh Now we've had COVID the hands on in doing time and even seeing patient's and even looking after the POSTOP patient is reduced. Uh We're going to reconcile that because you have been involved in simulation. Is there any way we can bring the two together to reduce the time and doing time. Well, you've already alluded to the boring stuff is useful if you understand what you're doing is more than just boring. Yeah. If you engage your brain when you're doing it, uh, well, I mean, it's best of all. If you engage your brain, you don't engage your brain, it's still different from not having done. Uh, and sometimes you can engage your brain retrospect if you, if you like. Um I mean, I think this is a reference, I think Erickson was people, I'm sure we'll know about K Anders Ericsson who died what, two years ago, something like that, um who came up with this sort of mantra as it has turned into. Uh And I think there are often misunderstandings about his work. So Erickson did a lot of work earlier in his career, looking at, looking at the experience of people he regarded as experts and he chose, didn't he people like elite musicians? Uh and, and some athletes and, and things like that. And he looked at what lay behind, what was it gone into their preparation that, that allowed them to become elite musicians, say violence or whatever. And he, he discovered that all of them had practiced for a very long time. Uh and, and he totted it up and it turned out to be $10,000 as a rule of thumb or 10 years of what he called sustained, deliberate practice with the intention to improve. So it wasn't just doing stuff, it was doing it with the intention to get better. Um I think this, this then became kind of popularized, it became uh popularized by people like Malcolm Gladwell and various other people who wrote popular books about it. Uh And, and often I think, took a lot of credit for from a gazing the idea and I think the idea makes a lot of sense that you have to do an awful lot of work in order to get really good at something. I think there are a couple of bits there that, that can lead to misunderstandings. One is that if you spend 10,000 hours doing something, you'll become an expert. And I think that's not necessarily, I think the, so the corollary of Ericsson's um assertion does not hold necessarily. So you can say that everybody who is expert as, as he did has done that amount of uh that amount of practice. But you cannot say that people who do that amount of practice will necessarily become expert because you can spend an awful lot of time, not getting much better, but just being there and doing things repetitive lee without making much sense of it. Um And I think that's an important distinction to draw because I think that there is something important about how, how you make use of the time that you have. Uh And the other thing that Eric's and I think if you read his work makes clear is that behind all those people he looked at who became internationally renowned violinists or swimmers or Olympic athletes or whatever were loads of other people who for years and years and years I got up and four in the morning to take them to the swimming pool or helped them making sure they did however many hours of practice it was, you know, none of these were solo efforts that they were always the result of a lot of support from other people. Um And so I think when we're thinking about how to, how to make sense of the change between a huge amount of being there and doing it, a huge amount of doing time, which in previous generations happened anyway, because that's what surgical training was like and it doesn't happen now. It didn't mean that all the people who did that became very good surgeons necessarily, some of them did, some of them became excellent surgeons, but there were bad surgeons to who were incompetent or who hadn't made good use of all that time. And so I think there's not a direct linear relationship between the time you spend and what comes out of that time, I think at its extremes, if the time is too short, then it is too short. Um But, but in the middle, there is something about making the best possible use of the time that is available. And a lot of that time, I think can be wasted if you go, for example, and spend a lot of time in the operating theater, not really being there, except in body and not trying to register what's going on or making sense of it, then you will get a much less effective experience than if you go there and you have all your five senses on full alert and you're trying to get what you can out of the opportunity. So I think there's something about how to make best use of the opportunities that are available because that is what the reality is now. And I do think that simulation can be very helpful, but it needs to be used intelligently and appropriately and it needs to do, it needs to be used for the things it does best and not just be seen as a carbon copy uh of what would otherwise happen in a clinical setting, but to be used thoughtfully so that the things that it offers can be, can help to accelerate people's acquisition of skills and the things that it isn't very good at. People don't waste their time on. And then coming back to your gentlemen, Joshua is making the pockets, the masterchef um along and said, not good enough but not explain why. Um when in hospitals were in an environment where we need to perform, where error is not accepted and mistakes are not accepted, but we don't seem to have created these islands of learning where practice is expected and mistakes do happen. How, how do we bring the two together in a clinical environment, do you think? Yeah, it's a, it's a very interesting one, isn't it? Uh, I mean, I think, I think errors are often seen in a boundary where are there either as an error, not an error. But actually, I mean, all the time, every, where things are, sometimes they're going better than they are other times. And I think, I think the systems, uh, view of error is a very interesting one because, you know, in that apprentice stage, everybody knows that people are just beginning will make mistakes. And the system sort of acknowledges that and, and novices in a silversmith workshop aren't given priceless piece of civil to work that they start on, on things that don't really matter, don't they? And we'll, our patient's do matters. You've already our patient's do matter. Absolutely. But as medical students were not invited to do open heart surgery as the lead surgery right away are we, we, we do things where, where it is known that medical students or junior trainees are likely to make mistakes and therefore the way they are invited to take part protects them and the patient's and the system in general from those mistakes that they are known to make. If you look at the, at the other end, um, the people who have become masters really, they all know because they've been doing it for a very long time otherwise they wouldn't be masters. That error is inevitable and they've all made loads of mistakes of their own. Uh, and they understand what that feels like and of course, they don't want to do it, but they know that, that, that is an inevitable part of practice under wise ones recognize that people less experienced than them will be making errors and will need support because most people don't set out to make errors because they want to make errors. It's something that happens um unexpectedly and unintendedly. And they have a, I think they have a generosity of understanding that enables them to put themselves into the position of somebody who's made. And that is why when you make a really bad mistake, what you should do is go and speak to somebody who's really experienced and tell them about it. And almost certainly they will, they will have a much, a much better understanding then the people than the really vulnerable stage I think is the, is the genuine stage when you um and you go out into the world and you are seen by the world as being fit for independent practice. And that generally means not making mistakes. And if you make a mistake, you get crucified because the world is an unforgiving place. And I think that's a particularly vulnerable place for people who are making that transition from the sort of supported or overtly supported world of the workshop of somebody else's environment of the training of being a student or being in training or whatever it is. Too bang there you are, you're, it, you're a consultant, you or whatever it is. Um And of course, the day you start is only 24 hours since you were in that previous phase. But you know, you are at the, at, at a it is in a way a perilous time because the expectations of the world around you are very different and they're very unforgiving. And yet probably your own personal experience has not yet got to the point where you've, you've done it enough times and got out of problems and things to have become confident at dealing with error. And so I think that that's a stage we need to look out for because the training system is largely designed by elapsed time. You know, you become a doctor after six years and then you're out there and it's a different thing and then you go on an eight year training program or something, you become a consultant or whatever your equivalent is in other parts of the world, becoming an attending or whatever. And that does not necessarily at all a line with what has happened to you in your own experience and how much uh how much resilience you've built up. And so if something big and bad and nasty happens to you really early on, it can have absolutely devastating effect as well. Perhaps as a patient or patient's you're looking after. And I think that that's one of the problems with trying to, trying to fit these unique personal stories that we all of us have with an organizational system that, that can see things in an inflexible way based on chronological, based on time. I mean, do you think that makes sense? That certainly does? And as going to follow up as we close in, how, how should we be training used? You've seen experts in these different fields? You've seen the apprentice, the gentlemen, the craftsman, the mast, er, and you've been through surgery and seen other disciplines. What can we learn for surgical training? What are we missing? Uh, what can we add to? I agree with you. The newly appointed consultant is at risk of my fellow Sensei Chris Cody will agree that coaching and mentoring is vital at that stage. But what else should we add to? Well, I think, I think bringing out into the open some of these issues, I mean, the issue of error, I think is a very interesting one because there's a difference, isn't there between error and complications in surgery? You know, and, you know, partial gastrectomy or hemicolectomy or something has, I don't know, 5% risk of, uh, you know, complications, 5% complication rate of and that's not leakage or something like that or, or whatever it is. In, in any particular specialty and when that happens it's not, I mean, it may be, but usually it isn't because anybody has made a mistake. It's because if you do 100 of them then five of them that will happen and, you know, if it doesn't happen to you, it's probably just because you haven't done enough of them. Not because you're particularly. Yeah. And so, so there is, there is that sense that the work that we do has unpredictability is around it. We're working with living human people, they're all different, you know, all these unpredictable things and, and, and that is an acknowledged thing that doesn't attract blame or shouldn't. I think it's very different when it comes to error. And obviously, if you cut off the wrong, whatever, very clear that there has been a bad mistake that shouldn't have happened and it happened. It's your fortunate, you know, but, but actually a lot of, a lot of the things that go wrong are, are not not blameworthy in the fact that some in the sense that somebody was drunk or incompetent or whatever, it's that bad things happened. And, and there's a big cultural problem, I think in how we deal with that because we still, despite all the stuff that goes on about human factors and all the rest of it, we still tend to escape goats and look at the person who's at the end of the firing line, even when it's a, it's a series of errors and things like that. So I think there's an awful lot we can do in trying to, trying to address the culture and, uh, rather, rather than pillory people end up in a narrow spotlight and, and acknowledge that things going slightly wrong is something that happens all the time, things going badly wrong is something that happens very seldom. But, you know, recognizing that that is a continuum and, and sort of giving people, I hope the confidence to recognize that as a normal part of surgical practice, but try and becoming, become more alert to when things are, are reaching, uh, sort of danger, I think would be a much more constructive way than pretending it doesn't happen and then crucifying people when it does. So Roger to close them, what would your advice be to the training surgeon today? Well, I think, I think one of them would be to spend as much time as you can, becoming as good as you can with your hands because I think that is really important and it's easy for that bit to be left out. And there are many ways that you can do that. I mean, you know, the traditional sort of time knots on the black chair with a piece of string kind of thing is sort of rather look down upon. But, but I think that there are a lot of things that, that people can do, um, that that can, that can counteract, I mean, people have a lot of agency and, and, and then if you recognize that, that what is often framed as boring, repetitive work of no apparent value is in fact valuable work of great value. Then you can, you can do your best to seek out opportunities to do that kind of work. Um whether it's in the area that you want to practice in, whether it's in the operating, that if you want to be a surgeon or whether it's something else that, that, that allows you to develop parallel skills of dexterity or precision or, or close noticing or any of those things. If you, if you recognize those as important parts of the work that you're going to be able to do, then you can think creatively about what activities you can engage in that allow you to practice those things, look around you. And if you can think of other people who do things that are sort of related to that and then spend your time learning to do those things as well. I mean, you know, your, your, your, your, I know you're a very expert marshal artist, but I'm quite sure there are many, many things about that, that you can, that you do apply or, and that you encourage other people to apply in terms of how you approach situations for instance. But often that needs to be made clear because it would seem that somebody who's the fifth down in Japanese swordsmanship or something would have nothing to do with somebody who's doing heart valve replacements. But if you're thinking about calmness and not committing yourself too soon, uh you know, knowing exactly what you do in terms of how much energy you put into a movement, all that kind of thing. If you make that clear, then people, it will help people make the connections between things that may seem unconnected. But what I've learned from, from all the stuff I've been doing and from reading this book is that if you, if you have a sense of what you're looking at, in, in my case, it was what it is to become expert. You can see how the experiences of different people connect and shine different kinds of light onto a single theme. And maybe that that's one of the things that we can encourage people watching to do is to think are there areas outside their primary area that that would help them and, and shine different lights um through these ideas of repetitive practice of uh of learning to improvise and of supporting other people as you become more experienced, just picking up on the improvise. Can we accept any improvisation today due to lack of enough exposure or practice or knowledge? So you say that again, can, can we form a question for one of our viewers? Can we accept any improvisation today? Due to lack of enough exposure practice? Or knowledge depends what you mean by improvisation. I mean, I think this is a really important one because the word improvisation, I think often has a bad press. Think people think that it means doing something off the cuff, you know, just that you haven't really taken to travel, to do properly. I don't think it's that at all. I think absolutely. On the contrary, I think improvising is a very high level of skill and it is the ability I think of being able to bring into play it extremely short notice. Um Relevant things from your past experience and your reading and your thinking that enabled you to address the situation you haven't encountered um in very short order. And so in order to be able to improvise, you need to have a lot of experience, you need to build up experience, but you also need to have the agility to recognize what you need to draw on and draw on it often very fast when things are slipping sideways. And that to me is improvisation and it is the opposite of lazy slipshod. Um not being able to be bothered to do it properly. It is a very high form of doing it properly, but it's something that you need to be able to be. But it, it is by its nature, a response to the unexpected. And I think that's what makes expert, expert very often is their ability to respond in the moment to a new situation and carry it off successfully. I think that's an excellent example. And I was just thinking of all the jazz records that I've got downstairs and jazz is a good example. Roger. I'm extremely grateful for your time, your insight and for those in the audience who would like to follow you put in the chat room. Roger has 100 and 85 podcasts with experts in various domains, talking through these subjects. We have only touched the surface this evening. I do recommend this as a read, very enlightening challenge. My thinking too. Thank you very much. Indeed, Roger and Gabrielle. Thank you again for your production and hosting behind the scenes. Well, it's been a great pleasure and thank you for inviting me absolute pleasure. Thank you very much and we'll say goodnight, good day wherever you are and look forward to seeing you next week where we'll go extend our learning on posture and we'll talk about Aristotle and Nuclear. Yes, theory and geometry. Do play a part in surgery. Thank you.