Trial and Error
I think there’s a misconception about the phrase trial and error. Perhaps this is because it contains the word ‘error.’ The misconception likely stems from what we want to believe about the process of learning. Can we learn risky tasks through trial and error? Most people are uncomfortable with this thought. Take surgery for example. Would you want there to be any error associated with fixing your life or limb? I wouldn’t. Then how is it done? Are such tasks so different than anything else in life?
We have an 11 month old at home who is learning how to walk. It is both endearing and fascinating. Two weeks ago he put 2 steps together. A week later he was doing 4-5 at a time. Today he is turning corners and going on full fledged jaunts. What is so awe inspiring is that the whole process has been one of trial and error: for every new step there have been 2 dozen missteps. For every milestone there have been countless falls. The cumulative effect however, has been the inexorable march toward bipedal locomotion. Undeterred, the little boy each day has built on his falls and now makes less of them…and walks.
Walking is one of the most fundamentally human traits that there is. And learning how to do it is not without risk (babies can and do fall and hit hard objects). So if it can be learned by trial and error then why not just about anything else?
We are conditioned to believe that our most important learning comes from the 20 or so years of time we spend sitting behind a desk reading text books. This is especially true of doctors: they are rewarded for getting good grades and enduring long years of schooling. However, while it is comfortable to think that your “brilliant” doctor soaked up most of his or her knowledge this way, it is not nearly the entire story. After a firm foundation was built in the classroom in anatomy, physiology etc.- their “brilliance” was often won through hard fought trial and error.
Example. Gary Gartsman is a famous shoulder surgeon best known for his contributions to the field of arthroscopic surgery. I had the privilege of attending one of his surgical skills courses on arthroscopic rotator cuff repair. There he recounted his introduction to arthroscopic surgery. Not only was his formal training rather bereft of hands on exposure to arthroscopy, but he found it rather unpleasant and had no intention on pursuing it in practice. But, as so often happens in life, he fell into the field by chance. In his first job he was the junior surgeon in an orthopedic group and his partner decided that he would be the “scope guy.” And since there was no book at the time from which he could study, he set out to teach himself.
His account of this process was no less than a course in controlled trial and error. To teach himself arthroscopic shoulder surgery, Gartsman would set a time limit for doing the case with the scope, beyond which he would convert the case to an open approach. Along the way he made mistakes- an errant portal placement here, a broken suture there- but he always had a back up plan. He risked an amount that allowed him small enough failures from which he could keep learning but not so large to derail the case or his duty to the patient. After enough trial and error and conscious self review, he was eventually able to complete the arthroscopic repairs from start to finish with the same level of competence as his open repairs. In time he was a master.
Walking is a series of steps. So is every surgical case- portal placement, suture grasping, knot tying- sometimes hundreds strung together in a specific sequence. Each one builds on the other. And some spell more consequence for the surgeon. Some can make or break a case on their own, others are a short stepping stone. While every surgery is built on a solid core of anatomical knowledge, surgery is learned in part by trial and error.
