No matter how well trained people are, few can sustain their best performance on their own. Thats where coaching comes in. Credit Illustration by Barry Blitt

Ive been a surgeon for eight years. For the past couple of them, my performance in the operating room has reached a plateau. Id like to think its a good thingIve arrived at my professional peak. But mainly it seems as if Ive just stopped getting better.

During the first two or three years in practice, your skills seem to improve almost daily. Its not about hand-eye cordinationyou have that down halfway through your residency. As one of my professors once explained, doing surgery is no more physically difficult than writing in cursive. Surgical mastery is about familiarity and judgment. You learn the problems that can occur during a particular procedure or with a particular condition, and you learn how to either prevent or respond to those problems.

Say youve got a patient who needs surgery for appendicitis. These days, surgeons will typically do a laparoscopic appendectomy. You slide a small cameraa laparoscopeinto the abdomen through a quarter-inch incision near the belly button, insert a long grasper through an incision beneath the waistline, and push a device for stapling and cutting through an incision in the left lower abdomen. Use the grasper to pick up the finger-size appendix, fire the stapler across its base and across the vessels feeding it, drop the severed organ into a plastic bag, and pull it out. Close up, and youre done. Thats how you like it to go, anyway. But often it doesnt.

Even before you start, you need to make some judgments. Unusual anatomy, severe obesity, or internal scars from previous abdominal surgery could make it difficult to get the camera in safely; you dont want to poke it into a loop of intestine. You have to decide which camera-insertion method to usetheres a range of optionsor whether to abandon the high-tech approach and do the operation the traditional way, with a wide-open incision that lets you see everything directly. If you do get your camera and instruments inside, you may have trouble grasping the appendix. Infection turns it into a fat, bloody, inflamed worm that sticks to everything around itbowel, blood vessels, an ovary, the pelvic sidewalland to free it you have to choose from a variety of tools and techniques. You can use a long cotton-tipped instrument to try to push the surrounding attachments away. You can use electrocautery, a hook, a pair of scissors, a sharp-tip dissector, a blunt-tip dissector, a right-angle dissector, or a suction device. You can adjust the operating table so that the patients head is down and his feet are up, allowing gravity to pull the viscera in the right direction. Or you can just grab whatever part of the appendix is visible and pull really hard.

Once you have the little organ in view, you may find that appendicitis was the wrong diagnosis. It might be a tumor of the appendix, Crohns disease, or an ovarian condition that happened to have inflamed the nearby appendix. Then youd have to decide whether you need additional equipment or personnelmaybe its time to enlist another surgeon.

Over time, you learn how to head off problems, and, when you cant, you arrive at solutions with less fumbling and more assurance. After eight years, Ive performed more than two thousand operations. Three-quarters have involved my specialty, endocrine surgerysurgery for endocrine organs such as the thyroid, the parathyroid, and the adrenal glands. The rest have involved everything from simple biopsies to colon cancer. For my specialized cases, Ive come to know most of the serious difficulties that could arise, and have worked out solutions. For the others, Ive gained confidence in my ability to handle a wide range of situations, and to improvise when necessary.

As I went along, I compared my results against national data, and I began beating the averages. My rates of complications moved steadily lower and lower. And then, a couple of years ago, they didnt. It started to seem that the only direction things could go from here was the wrong one.

Maybe this is what happens when you turn forty-five. Surgery is, at least, a relatively late-peaking career. Its not like mathematics or baseball or pop music, where your best work is often behind you by the time youre thirty. Jobs that involve the complexities of people or nature seem to take the longest to master: the average age at which S. & P. 500 chief executive officers are hired is fifty-two, and the age of maximum productivity for geologists, one study estimated, is around fifty-four. Surgeons apparently fall somewhere between the extremes, requiring both physical stamina and the judgment that comes with experience. Apparently, Id arrived at that middle point.

It wouldnt have been the first time Id hit a plateau. I grew up in Ohio, and when I was in high school I hoped to become a serious tennis player. But I peaked at seventeen. That was the year that Danny Trevas and I climbed to the top tier for doubles in the Ohio Valley. I qualified to play singles in a couple of national tournaments, only to be smothered in the first round both times. The kids at that level were playing a different game than I was. At Stanford, where I went to college, the tennis team ranked No. 1 in the nation, and I had no chance of being picked. That meant spending the past twenty-five years trying to slow the steady decline of my game.

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Personal Best - The New Yorker