Here is the full transcript of American surgeon Atul Gawande’s Talk: Want to Get Great at Something? Get a Coach at TED conference.
Atul Gawande – Surgeon
I don’t come to you today as an expert. I come to you as someone who has been really interested in how I get better at what I do and how we all do.
I think it’s not just how good you are now, I think it’s how good you’re going to be that really matters. I was visiting this birth center in the north of India. I was watching the birth attendants, and I realized I was witnessing in them an extreme form of this very struggle, which is how people improve in the face of complexity — or don’t.
The women here are delivering in a region where the typical birth center has a one-in-20 death rate for the babies, and the moms are dying at a rate ten times higher than they do elsewhere. Now, we’ve known the critical practices that stop the big killers in birth for decades, and the thing about it is that even in this place — in this place especially, the simplest things are not simple.
We know, for example, you should wash hands and put on clean gloves, but here, the tap is in another room, and they don’t have clean gloves. To reuse their gloves, they wash them in this basin of dilute bleach, but you can see there’s still blood on the gloves from the last delivery. Ten percent of babies are born with difficulty breathing everywhere. We know what to do. You dry the baby with a clean cloth to stimulate them to breathe.
If they don’t start to breathe, you suction out their airways. And if that doesn’t work, you give them breaths with the baby mask. But these are skills that they’ve learned mostly from textbooks, and that baby mask is broken. In this one disturbing image for me is a picture that brings home just how dire the situation is. This is a baby 10 minutes after birth, and he’s alive, but only just.
No clean cloth, has not been dried, not warming skin to skin, an unsterile clamp across the cord. He’s an infection waiting to happen, and he’s losing his temperature by the minute. Successful child delivery requires a successful team of people. A whole team has to be skilled and coordinated; the nurses who do the deliveries in a place like this, the doctor who backs them up, the supply clerk who’s responsible for 22 critical drugs and supplies being in stock and at the bedside, the medical officer in charge, responsible for the quality of the whole facility. The thing is they are all experienced professionals.
I didn’t meet anybody who hadn’t been part of thousands of deliveries. But against the complexities that they face, they seem to be at their limits. They were not getting better anymore. It’s how good you’re going to be that really matters. It presses on a fundamental question: How do professionals get better at what they do? How do they get great?
And there are two views about this. One is the traditional pedagogical view. That is that you go to school, you study, you practice, you learn, you graduate, and then you go out into the world and you make your way on your own. A professional is someone who is capable of managing their own improvement. That is the approach that virtually all professionals have learned by. That’s how doctors learn, that’s how lawyers do, scientists musicians. And the thing is, it works.
Consider. for example. legendary Juilliard violin instructor Dorothy DeLay. She trained an amazing roster of violin virtuosos: Midori, Sarah Chang, Itzhak Perlman. Each of them came to her as young talents, and they worked with her over years. What she worked on most, she said, was inculcating in them habits of thinking and of learning so that they could make their way in the world without her when they were done.
Now, the contrasting view comes out of sports. And they say “You are never done, everybody needs a coach.” Everyone. The greatest in the world needs a coach. So I tried to think about this as a surgeon. Pay someone to come into my operating room, observe me and critique me. That seems absurd.
Expertise means not needing to be coached. So then which view is right? I learned that coaching came into sports as a very American idea. In 1875, Harvard and Yale played one of the very first American-rules football games. Yale hired a head coach; Harvard did not. The results? Over the next three decades, Harvard won just four times. Harvard hired a coach. And it became the way that sports works.
But is it necessary then? Does it transfer into other fields? I decided to ask, of all people, Itzhak Perlman. He had trained the Dorothy DeLay way and became arguably the greatest violinist of his generation. One of the beautiful things about getting to write for “The New Yorker” is I call people up, and they return my phone calls. And Perlman returned my phone call. So we ended up having an almost two-hour conversation about how he got to where he got in his career.
And I asked him, I said, “Why don’t violinists have coaches?”
And he said, “I don’t know, but I always had a coach.”
“You always had a coach?”
“Oh yeah, my wife, Toby.”
They had graduated together from Juilliard, and she had given up her job as a concert violinist to be his coach, sitting in the audience, observing him and giving him feedback. “Itzhak, in that middle section, you know you sounded a little bit mechanical. What can you differently next time?” It was crucial to everything he became, he said. Turns out there are numerous problems in making it on your own. You don’t recognize the issues that are standing in your way or if you do, you don’t necessarily know how to fix them.
And the result is that somewhere along the way, you stop improving. And I thought about that, and I realized that was exactly what had happened to me as a surgeon. I’d entered practice in 2003, and for the first several years, it was just this steady, upward improvement in my learning curve. I watched my complication rates drop from one year to the next. And after about five years, they leveled out.