Pulse Check with Dean Nelson - September 2026
Sharing thoughts, laughs, and a little wisdom!
The Work Between the Work
There is a moment in medical training when watching is no longer enough.
A student has stood beside you through enough cases to understand the rhythm. They have watched you take a history, examine a patient, explain a diagnosis, and make a decision when the answer was not obvious. Then one day you step back and say, "You do it."
It feels like a small moment, but it isn’t. It is the beginning of learning to work independently.
Psychologist K. Anders Ericsson spent much of his career studying how people become experts. His research gave us the concept of deliberate practice — the idea that expertise is not simply the result of doing something repeatedly. We improve when we work on something specific, at the edge of our ability, and get feedback from someone who knows what good performance looks like.
Medicine is full of examples of this.
A physician can perform the same task for twenty years and become very experienced at doing it the same way. Experience matters, of course, but experience and improvement aren't always the same thing. Getting better through deliberate practice requires us to occasionally stop and ask: What am I trying to improve? What did I miss? What should I do differently the next time?
Medicine has worked this way for generations, long before we called it deliberate practice. You watch someone who knows the craft. You try it yourself. Someone more experienced watches you and points out what you missed. Then they let you try again. Over time, you need the teacher less. That's the point.
You can see this progression throughout academic medicine. A first-year medical student learns how to perform a physical examination. By third year, the student begins to recognize which findings matter. A resident learns to make decisions with less supervision. The same thing happens in a research laboratory, where a graduate student learns a technique and eventually finds herself teaching it to someone else.
The remarkable part is that the knowledge does not simply move from one person to another. It evolves along the way. Students and trainees absorb what they learn, adapt it, and eventually make it their own. Knowledge is passed forward, but never unchanged.
Students become physicians and scientists, and eventually many of them become teachers themselves. They take pieces of what they learned from different people and develop their own way of doing things.
This is one reason I have always believed in the value in having more than one mentor. Two very good physicians—or scientists—can look at the same problem differently. Learning from those differences is part of developing your own judgment.
None of this becomes less important as technology improves.
Simulation, digital learning, and now artificial intelligence can give students remarkable opportunities to practice and learn. AI can retrieve information in seconds and inform decision-making. Simulators can repeatedly reproduce clinical scenarios with subtle differences. These are powerful tools, and they will only get better.
But there is still something different about having an experienced person standing next to you who says, "Look again."
Or asks, "Why did you choose that?"
Or tells you, "You were right about the diagnosis, but you missed what the patient was trying to tell you."
I've come to think that a lot of medical education happens in moments like these. They aren't the moments we usually photograph. We photograph the White Coat Ceremony or Match Day. We celebrate graduations and promotions. Those milestones matter.
But most of the actual learning happens in between them. A student asks one more question. A graduate student runs the experiment again because the first one didn't work as hoped. A clinical faculty member pauses during rounds to explain why a seemingly insignificant finding matter. Someone gets feedback they don't particularly want to hear, thinks about it, and comes back the next day determined to do better.
That’s the work between the work.
Eventually, the person who once stood beside someone else learning what to do finds themselves on the other side of the relationship.
First, it is:
“Watch me."
Then:
"Your turn."
Perhaps that is one of the most important things we teach in medicine: not simply what to know, but how to keep getting better.
Wax On, Wax Off
There is a scene in The Karate Kid that I suspect most of us remember, even if we haven't seen the movie in decades.
Daniel wants to learn karate. Mr. Miyagi apparently has other plans. He tells Daniel to wax his cars, sand the floor, and paint his fence. Daniel does what he's told until, understandably, he gets fed up. He came to learn karate, and instead he seems to have become Mr. Miyagi's unpaid handyman.
Of course, that's not what's happening.
Daniel has been learning karate the entire time. The movements that seem pointless are teaching him coordination, balance, and muscle memory. Mr. Miyagi understands something Daniel does not yet understand: sometimes you have to learn how to do something before you fully understand why you're doing it.
Medicine and science have a lot of wax-on, wax-off moments.
Think about learning to take a patient history. At first, you're mostly trying to remember all the questions you're supposed to ask. With enough experience, something changes. You stop working through the checklist and start listening to the story.
The same thing happens in the laboratory. A graduate student learning a new technique may initially be focused on following the protocol exactly: measure this, add that, wait this long. After doing it enough times, the mechanics become second nature.
More importantly, the student begins to understand why each step matters, what can go wrong, and when a result doesn't quite make sense.
That is when following a protocol or algorithm starts to become thinking like a scientist or a clinician.
It happens with clinical procedures, too. Early on, you're thinking about every individual step. Eventually, the mechanics become second nature and you can pay attention to everything else happening around you.
Some things are even harder to teach. There is no textbook that can really prepare a young physician to sit down with a patient or family and deliver terrible news. Nor can a protocol teach a young scientist what to do when months of experiments produce a result that contradicts the hypothesis. In both cases, you learn partly by watching someone who has been there before.
This is where a good teacher matters.
A good teacher doesn't simply tell you what to do. They watch you do it. They let you struggle a little, step in when needed, and point out something you didn't see. Then they let you try again.
Sometimes the lesson is technical. Sometimes it's about the patient or the experiment. And sometimes it's about you.
That's apprenticeship. It happens at the bedside, in the operating room, and at the laboratory bench. You learn the craft by working alongside someone who has already learned it—and, eventually, by doing it without them.
We call a lot of that "experience," but I think it's more than that. Experience is doing something many times. The real value of apprenticeship is having someone help you understand what you should be noticing while you're doing it.
Over time, that becomes judgment.
And if the apprenticeship works, eventually you find yourself on the other side of the relationship, watching someone else struggle with something you've done a thousand times.
You let them struggle a little.
Then you say, "Try it this way."
Wax on.
Stay curious, MedOwls.