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responsibility. And there is reason to think patients actually benefit from teaching. Studies generally find teaching hospitals have better outcomes than non-teaching hospitals. Residents may be amateurs, but having them around checking on patients, asking questions, and keeping faculty on their toes seems to help. But there is still no getting around those first few unsteady times a young physician tries to put in a central line, remove a breast cancer, or sew together two segments of colon. No matter how many protections we put in place, on average these cases go less well with the novice than with someone experienced.
    We have no illusions about this. When an attending physician brings a sick family member in for surgery, people at the hospital think hard about how much to let trainees participate. Even when the attending insists that they participate as usual, a resident scrubbing in knows that it will be far from a teaching case. And if a central line must be put in, a first-timer is certainly not going to do it. Conversely, the ward services and clinics where residents have the most responsibility are populated by the poor, the uninsured, the drunk, and the demented. Residents have few opportunities nowadays to operate independently, without the attending docs scrubbed in, but when we do—as we must before graduating and going out to operate on our own—it is generally on these, the humblest of patients.
    This is the uncomfortable truth about teaching. By traditional ethics and public insistence (not to mention court rulings), a patient’s right to the best care possible must trump the objective of training novices. We want perfection without practice. Yet everyone is harmed if no one is trained for the future. So learning is hidden, behind drapes and anesthesia and the elisions of language. Nor does the dilemma apply just to residents, physicians in training. Infact, the process of learning turns out to extend longer than most people know.
    My sister and I grew up in the small town of Athens, Ohio, where our parents are both doctors. Long ago my mother chose to practice pediatrics part-time, only three half-days a week, and she was able to because my father’s urology practice became so busy and successful. He has now been at it for more than twenty-five years, and his office is cluttered with the evidence of it: an overflowing wall of patient files, gifts from people displayed everywhere (books, paintings, ceramics with biblical sayings, hand-painted paperweights, blown glass, and carved boxes, as well as a figurine of a boy who pees on you when you pull down his pants). In an acrylic case behind his oak desk there are a few dozen of the thousands of kidney stones he has removed from these patients.
    Only now, as I get glimpses of the end of my training, have I begun to think hard about my father’s success. For most of residency, I thought of surgery as a more or less fixed body of knowledge and skill which is acquired in training and perfected in practice. There was, as I envisioned it, a smooth, upward-sloping arc of proficiency at some rarefied set of tasks (for me, taking out gallbladders, colon cancers, bullets, and appendices; for him, taking out kidney stones, testicular cancers, and swollen prostates). The are would peak at, say, ten or fifteen years, plateau for a long time, and perhaps tail off a little in the final five years before retirement. The reality, however, turns out to be far messier. You do get good at certain things, my father tells me, but no sooner than you do, you find what you know is outmoded. New technologies and operations emerge to supplant the old, and the learning curve starts all over again. “Three-quarters of what I do today I never learned in residency,” he says. On his own, fifty miles from his nearest colleague—let alone a doctor who could tell him anything like “You need to turn your wrist more when you do that”—he has had to learn to put in penile prostheses, to