Last winter, I was on the phone with Richard Whelan, MD, professor of surgery and chief of surgical oncology at St. Luke’s-Roosevelt Hospital in New York City, discussing his thoughts about the early days of laparoscopic colorectal surgery [see History of Lap Colectomy in the May 2014 issue of GSN for more]. During our conversation, he became excited when he mentioned the rare surgical talent possessed by his colleague Morris Franklin, MD, director of the Texas Endosurgery Institute, noting how even today Dr. Franklin’s skill set “is hard to match.”
 
In an almost off-hand remark Lee Cohen, former head of laparoscopic marketing and technology at US Surgical in Norwalk, Conn., echoed this sentiment about Dr. Franklin’s unique ability: “What Morris Franklin can do, well you can’t necessarily teach such advanced technique.”
 
When I spoke to Dr. Franklin, I was fully expecting him to take a deep breath and reveal to me the magic of his hands, that in fact he had always had an innate talent for grasping how the body works and how to fix it. But his response surprised me.
 
Dr. Franklin explained that, yes he may have been blessed with some natural ability, but it was practice, practice and more practice that allowed him to develop such keen precision, depth of knowledge and mastery of difficult new skills. Dr. Franklin described that early in his career, even after a long day devoted to honing his laparoscopic techniques in a pig lab with colleagues, urologist William Schuessler, MD, and gynecologist Thierry Vancaillie, MD, he would still hunker down on evenings and weekends to practice. And, over 30 years later, he continues to modify and tweak his technique. “With luck, comes a lot of work,” he said.
 
True, training and repetition are essential to mastering any skill, but surely, even with the years of intense practice, masters of a trade such as Dr. Franklin must have an element of innate ability fueling their success. Otherwise, with some labor and perseverance, any person could potentially become an expert surgeon, and it’s quite clear this is not the case. So, truly how much of a surgeon’s skill is intrinsic and how much can be developed through hard work?
 
The question of nature versus nurture—the extent to which our genes or environment influence behavior—has been debated for decades. Sir Francis Galton, an English psychologist and anthropologist may have been the first to coin the phrase “nature versus nurture” in a 1874 publication, “On men of science, their nature and their nurture,” (Proc Roy Instit Gr Brit;7:227-236), and 140 years later, scientists are still trying to unravel this mystery.
 
For the most part, the consensus has been that “it’s always a hardware and software story,” as journalist David Epstein wrote in his new book The Sports Gene: Inside the Science of Extraordinary Athletic Performance (Current Hardcover, 2013). But, Epstein notes, when it comes to top athletes and others at the pinnacle of their profession, some simply have a gift, while others, no matter how much training they endure, will never measure up.
 
More recently, scientists have been looking to epigenetics to answers how our genes and environment interact to explain behavior or determine, for instance, whether we will develop a disease. Epigenetics is a hugely complex field, but the crux is that small molecules bind to, or unbind from, our DNA, prompting certain genes to turn on or off. However, teasing out what causes certain genes to be expressed or not remains problematic. How much can are our diets, exercise routines, stress levels, friends really impact us on the level of our genes? We don’t yet have answers.
 
What we do know, however, is that certain people have a genetic makeup that makes them more susceptible to environmental influences and others more resilient. To make matters more complex, a crop of studies is now showing that some epigenetic changes persist over generations. For instance, neurobiologists at Emory University revealed that when they trained mice to fear the scent of acetophenone, a sweet smelling chemical, many of their offspring were also more sensitive to the odor, acting more skittish in its presence (Nature Neurosci 2014;17;89-96). This sensitivity even extended to the grandchildren of the initial group of mice. What’s more, all three generations exhibited the same changes in an odor receptor called Olfr151, which becomes active in the presence of acetophenone. The researchers suggest that epigenetic changes may explain how a fear of acetophenone persisted over several generations.
 
Bearing this in mind, the question of whether surgeons are born or made becomes more convoluted. On one level, perhaps some surgeons have the right mix of natural ability and dedication to achieve the level of mastery that the Dr. Franklins of this world possess, and perhaps others will never reach that level no matter how much time they spend training. But it is interesting to consider how epigenetics may factor in as well. As recent work suggests, there may be more subtle influences that play into a person’s success. I wonder, for instance, whether watching our parents practice their professions obsessively can influence the degree to which we are motivated to practice. In other words, is the tendency to practice something more genetic, epigenetic or trained? Or, perhaps these influences are too subtle to make a difference.
 
I bring this topic up not because I am suggesting that medical school admissions or even residency matching take into account general characteristics of parents or environmental influences to get a sense of genetic or epigenetic advantages. But as surgeons continue to debate the quantity and quality of resident training and the disparities in patient outcomes after surgery, I wonder whether it is possible to garner greater insight into how the best of the best train, live, think and practice will help us understand how all surgeons can strengthen their operative skills.
 
See my next blog for a look at whether new surgeons are prepared to practice.