"If you're doing an operation, you have to get ready beforehand. You spend years learning how to do it, and once you've started, you have to finish. It makes sense to look at how these aspects of performing play out in different areas of expert practice."
Roger Kneebone’s is a Professor of Surgical Education and an expert on Experts. After training as a trauma surgeon in the 1980s he spent 5 years in some of the mot violent parts of South Africa. When he returned to England he became a GP. 17 years later he changed direction again and helped develop the field of surgical education at Imperial College London. Now he divides his times between teaching and speaking following the publication of his book 'Expert' which examines how the path of mastery crosses so many different fields.
In the book, I look at this process of becoming an expert: when you start out you spend years doing what other people tell you, then you're good enough to go out and make a living at it. And then finally, you're so experienced that you can pass that on to other people.
You’re turning knowledge into wisdom all the way along. At each stage, you are getting things wrong and having to fix them and this gives you an accumulating repository of solutions that you can draw on the next time.
This is what wisdom depends on, I think, because it allows you to make sensible choices that take into account the needs of other people. For example, someone might choose not to operate, because it is in the best interest of their patient to wait and see.
Things like this require thoughtful, attentive concern, but also a sense of detachment. That's what wisdom brings.
I think it depends on what you mean by leadership. If by leadership you mean going up in a hierarchical institution and having more and more people working under you, that's a different thing from leadership in the sense of taking into account somebody's needs and helping them move in a direction that is aligned with where you want them to go and where they want to go.
I think that you can have very good leaders who are only leading two or three people, and you have very bad leaders who are leading 500 or more.
Some people as they get older, their careers and the opportunities available to them can change. Some things close down and new things open up. People often feel that there is a pressure on them to take on a more senior, more complex and more elevated role, but I don't think that always works.
There are some people who may have been excellent leaders of research groups, who go and become vice chancellors of universities for example, and it doesn't suit them. It’s a very personal thing.
One of the elements of wisdom is knowing what you're good at and what you're not and having the confidence to say no to things that aren't a good fit, even if you're flattered to be asked.
When I began, I don't think I really knew what the traditional ladder was. I started off as a medical student; I spent some time doing orthopedics; working in accident and emergency; a year doing obstetrics.
I wasn’t quite sure what to do, but then I had the opportunity to go to spend a year in Africa, which I thought would be a fascinating opportunity. I went to Johannesburg and worked largely on trauma surgery. One year turned into two years. Two years turned into five. I spent time running a trauma unit in a pediatric hospital in Cape Town, and then went for a few months to work in what turned out to be a war zone in Namibia.
When I returned to the UK after five years away, I didn’t really know what to do next.
I answered an advertisement in an out-of-date copy of the British Medical Journal, and ended up at a GP training practice in Lichfield that had a history of taking people with unconventional experiences, who have been overseas and the like. I spent a very interesting year in Litchfield as a GP trainee and then joined to practice in Wiltshire.
When I became a GP, I thought it would be much the same as I'd already been doing, but it was a completely different kind of work, really. It was very much about working with individuals. Sometimes it was straightforwardly medical: somebody had a chest infection, so they probably needed antibiotics.
But it was a very different thing if we were looking at a problem with someone’s child and truancy at school, for example. I had to deal with things that I hadn’t necessarily learned in medical school. With specialist hospital practice, you’re able to push aside all the things that are not in your specific category, but in general practice it’s very different.
That was fascinating to me, and alongside my interest in teaching, was what led to me becoming a GP trainer.
I became increasingly interested in GP training, and at the same time my interest grew in a different kind of teaching: minor surgery in general practice.
There needed to be a more structured training programme and I had an opportunity to develop a national training programme for GPs using simulation. I collaborated with a new company, run by a medical artist, to create a range of latex and silicon models of different parts of the body that students could practice on.
Later I moved to Kings College, to develop the field of surgical education.
A big part of this was bringing in perspectives from education outside of medicine - perspectives from the humanities, the social sciences, school education, young people, special needs - all kinds of things. I was particularly interested in critically engaging with the literature from the social sciences, which is quite often uncomfortable for people who have been trained medically.
At the same time I developed this idea of simulation and then was very fortunate in getting an engagement fellowship with the Wellcome Trust, which gave me a lot of time to explore ideas about how to connect with all kinds of different people from the world of medicine and surgery.
That’s when I started looking at surgery not simply as operating on a sick person to make them better, but as an instance of craftsmanship or performance. As part of this I invited craftsmen and performers from other areas and industries to come and experience surgical work through simulation and then have conversations about what we might each learn from one another.
I've done quite a lot with virtual reality and simulation science. One of the projects I lead is focused on trying to reduce the impact of knife crime on young people. We’ve used virtual reality to model the pathway: somebody gets stabbed, then there is roadside assistance, life-saving surgery and that person is then left with a life-changing consequence. All of this is shown through a virtual reality experience, but also through physical simulation, using actual surgeons and nurses, and silicon models of bodies.
It’s been very interesting to look at simulation as a means of showing not just a particular moment such as an operation, but a sequence of events - the whole process. You can condense four or five days worth [of events] into 20 minutes by seeing that theatrical sequence.
The other thing that could have a big impact is 3D printing. It's not my area of expertise, but in our group there is a lot of work using 3D printed models of newborn babies with particular congenital abnormalities, for example, or fractures of the facial bones. This means that students can practice putting on plates before they do that on an actual patient based on scans. There's also a huge amount of exciting work going on with robot assisted surgery.
One of the issues here is about how you use words. To clarify, sometimes people use the word ‘performing’ in a pejorative sense, which implies inauthenticity or deception. This isn’t what I’m talking about. For me, I’m talking about performance as the human experience of doing work and engaging with other people.
Once you start thinking like that, I think it makes much more sense to look at and learn from other people who do expert work, particularly if you can identify areas of similarity between their work and yours.
If you're doing an operation, you have to get ready beforehand. You spend years learning how to do it, you have to get ready and once you've started, you have to finish. Afterwards you may be full of adrenaline, then you step outside, you take the gloves off and all the adrenaline goes. If you think about it, that’s very similar to someone going on stage, or taking a penalty [in a football game]. It makes sense to look at how these aspects of performing play out in different areas of expert practice.
Connecting with people and having conversations is one thing; making sense of what they say is quite another. That’s the bit that I'm interested in: how to make sense of all these different perspectives that we can get from talking to, working with, watching and reading about other people.
Joshua Byrne is a bespoke tailor I've been working with for many years now. His idea of bespoke involves starting with a person and trying to work out what they want a garment to do for them and what it is they need, rather than starting off with a garment that has already been designed and making it fit. The idea is that success is measured by how it makes somebody feel, not just how it makes other people see them.
I think that has very interesting parallels with the clinical process and of the process between patient and doctor in the consulting room when you are a GP.
I’ve also learned a lot from close-up magicians Richard McDougall, David Owen and Will Houstoun. I’m very interested in how they develop the skill of shaping and directing people's attention through close observation, using eye contact and gesture to create a story during a magic show.
All the delicate, manipulative stuff - fascinating though it is - for me, is overshadowed by that extraordinary skill they have in shaping and managing the experience of somebody who's watching. I've learned a huge amount of that from them, about performing as a human experience.
Future at a Glance. A quick read of the latest thinking that’s been engaging the Spoken team, direct to your inbox
Somerset House
Strand
WC2R 1LA
London
