How do you get to Carnegie Hall? the old joke goes. Practice. Practice makes for great performance. Gladwell quantitated this notion, hypothesizing that it takes 10 000 hours of practice to be an elite performer in any activity requiring mechanical and technical skills.1 In a similar fashion, surgeons require a certain degree of experience to develop proficiency in performing an operation. However, problems arise when trying to define when a surgeon is competent to perform a difficult operation. How can technical competence be measured? Despite the great practical and societal importance of this question, it has yet to be answered in a satisfactory way.
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