Atul Gawande had been a surgeon for eight years and had done more than two thousand operations. For years he had compared his results with national data, and he had begun beating the averages. His complication rates moved steadily lower. Then, a couple of years before he wrote about it in 2011, they stopped falling.
The idea came from a tennis court. At a medical meeting on Nantucket, Gawande paid for a lesson with the club pro, a recent college graduate in his early twenties. The young man had him pay attention to his feet as he served, and Gawande noticed his right leg dragging a few inches behind. With a few minutes of tinkering, by Gawande’s account, the pro added at least ten miles an hour to his serve. Not long afterwards, watching Rafael Nadal on television, he was struck by the obvious: even Nadal had a coach. Surgeons did not.
He called a retired general surgeon he had trained under as a resident. The man was an unusual teacher. “He never quite told you what to do,” Gawande wrote. At Gawande’s first splenectomy as an intern, the teacher did not draw the incision line for him, as other professors did. He just stood there, waiting, until Gawande drew the incision himself. “Is that really where you want it?” he asked. Ten minutes in, it was obvious the cut was too small, and they had to extend it. It took Gawande a couple of years, he wrote, to realize that what scared him was not the man’s voice but his questions.
Now the old teacher stood on a step stool in Gawande’s operating room, taking notes, while Gawande removed a thyroid with a cancerous nodule. He had done the operation around a thousand times. It took 86 minutes and went beautifully. The coach had rarely done this operation himself, and Gawande wondered whether he would find anything useful to say.
In the surgeons’ lounge, the notepad turned out to be dense with small print. Gawande had draped the patient perfectly for himself but hemmed in his assistant across the table. At various points his right elbow rose to the level of his shoulder. “You cannot achieve precision with your elbow in the air,” the coach said. For about half an hour, the operating light had drifted out of the wound, and Gawande had not noticed. That one twenty-minute talk, Gawande wrote, gave him more to work on than he had had in the past five years.
They kept meeting. On a video of a later operation, the light drifted again, and Gawande caught it in four minutes instead of half an hour. The coach told him to let residents struggle thirty seconds longer before giving instructions: “Get them to think.”
It was not comfortable. When the coach watched a laparoscopic adrenal operation go wrong, with bleeding and a switch to open surgery, Gawande’s cheeks burned and he wished he had never asked him along. Afterwards the coach focused on what Gawande thought had gone well and what hadn’t, and asked him to think harder about the anatomy holding the tumor in.
In the 2011 article, Gawande wrote that his complication rate had gone down since he took on a coach, though it was too soon to be sure that wasn’t random. In a 2017 TED talk he said that after a year of coaching, his complications had dropped further.
“Who’s that?” one patient asked, spotting the man with the notebook before her anesthesia. “He’s like a coach,” Gawande finally said. She did not seem reassured.