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performmicrosurgery, to reverse vasectomies, to do nerve-sparing prostatectomies, to implant artificial urinary sphincters. He’s had to learn to use shock-wave lithotripters, electrohydraulic lithotripters, and laser lithotripters (all instruments for breaking up kidney stones); to deploy Double J ureteral stents and Silicone Figure Four Coil stents and Retro-Inject Multi-Length stents (don’t even ask); to maneuver fiber-optic ureteroscopes. All these technologies and techniques were introduced since he finished training. Some of the procedures built on previous skills. Many did not.
    This is, in fact, the experience all surgeons have. The pace of medical innovation has been unceasing, and surgeons have no choice but to give the new new thing a try. To fail to adopt new techniques would mean denying patients meaningful medical advances. Yet the perils of the learning curve are inescapable—no less in practice than in residency.
    For the established surgeon, inevitably, the opportunities for learning are far less structured than for a resident. When an important new device or procedure comes along, as they do every year, surgeons start out by taking a course about it—typically a day or two of lectures by some surgical grandees with a few film clips and step-by-step handouts. We take a video home to watch. Perhaps we pay a visit to observe a colleague perform the operation—my father often goes up to Ohio State or the Cleveland Clinic for this. But there’s not much by way of hands-on training. Unlike a resident, a visitor cannot scrub in on cases, and opportunities to practice on animals or cadavers are few and far between. (Britain, being Britain, actually bans surgeons from practicing on animals.) When the pulsed-dye laser came out, the manufacturer set up a lab in Columbus where urologists from the area could gain experience. But when my father went, the main experience provided was destroying kidney stones in test tubes filled with a urinelike liquid and trying to penetrate the shell of an egg without hitting the membrane underneath. My surgery department recently purchased a robotic surgery device—a staggeringly sophisticated nine-hundred-and-eighty-thousand-dollar robot,with three arms, two wrists, and a camera, all millimeters in diameter, which, controlled from a console, allows a surgeon to do almost any operation with absolutely no hand tremor and with only tiny incisions. A team of two surgeons and two nurses flew out to the manufacturer’s headquarters in San Jose for a full day of training on the machine. And they did get to practice on a pig and on a human cadaver. (The company apparently buys the cadavers from the city of San Francisco.) But even this, which is far more practice than one usually gets, was hardly thorough training. They learned enough to grasp the principles for operating the robot, to start getting a feel for using it, and to understand how to plan an operation. That was about it. Sooner or later, one just has to go home and give the thing a try.
    Patients do eventually benefit—often enormously—but the first few patients may not and may even be harmed. Consider the experience reported by the pediatric-surgery unit of the renowned Great Ormond Street Hospital in London, as detailed in the
British Medical Journal
in the spring of 2000. The doctors described their results in operating on three hundred and twenty-five consecutive babies with a severe heart defect, known as transposition of the great arteries, over a period (from 1978 to 1998) when its surgeons changed from doing one operation for the condition to another. Such children are born with their heart’s outflow vessels transposed: the aorta emerges from the right side of the heart instead of the left and the artery to the lungs emerges from the left instead of the right. As a result, blood coming in is pumped right back out to the body instead of first to the lungs, where it can be oxygenated. This is unsurvivable. The