I am honored to have been selected as the speaker for the 2022 John W. Duckett Memorial Lecture. Dr. Duckett was a giant in pediatric urology, participating in every leadership role within pediatric urology. Many tributes describe Dr. Duckett; one representative of his character was stated by Dr. James O’Neal: “...a man of superior intellect...he shared unselfishly with others from all over the world. He took pleasure in seeing his trainees succeed.” I didn’t train with Dr. Duckett but was influenced by him early in my career. Reflecting on hypospadias, Dr. Duckett stated, every year think about what you are doing, review your results, and learn from the outcome of others. That was my introduction into the importance of lifelong learning.

To understand lifelong learning, I did what my patients do. I searched Google, finding lifelong learning defined as “self-initiated, continuous education outside of a traditional institution, focused on personal development.” Philosophically, it is the essence of humanity and natural curiosity.

Hopefully lifelong learning creates a vision of a self-motivated commitment to long-term education. More likely, it brings visions of hurdles and hoops that one must conquer in order to fulfill requirements of state licensure, hospital credentialing, and continued board certification.

NORC at the University of Chicago surveyed a diverse group of individuals based on gender, race, ethnicity, education, and age: 98% assume their physician is up-to-date, 95% agree their physician should participate in an educational program, and 95% feel their physician should be required to demonstrate they are up-to-date in knowledge.¹ That expectation of lifelong learning places a burden on all physicians, taking time away from their family and practice at an expense that is not always reimbursed.² Physicians should ask, “Lifelong learning, what’s in it for me?” An easy response is “personal fulfillment, increased job satisfaction, staying abreast of knowledge, and improvement in cognition.” More importantly: “Does it make you a better urologist? Does it improve your clinical practice and patient outcomes?”

Time creates an exponential growth of medical knowledge, with urology one of the most affected specialties. Medical knowledge doubling time in 1950 was 50 years; in 1980, 7 years; and in 2020, 73 days (Fig. 1). A surgeon’s approach to patient care also transitions with time. During the first few years in practice, we are very analytical, questioning our understanding, evaluation, and treatment. The longer in practice we become more nonanalytical, relying on experience as our guide for evaluation and treatment.³ Life experience does breed proficiency and expertise. However, there is a misconception that anyone becoming an expert remains an expert. Keeping abreast of expanding medical knowledge and maintaining expertise establishes the foundation for lifelong learning.

The effect of age on a physician’s cognition is highly variable. Many occupations require mandatory retirement based solely on age (airline pilots aged 65 years, FBI agents 57 years, air traffic controllers 56 years), and some countries require surgeons to retire within their 60s. However, age as a single factor doesn’t predict competence, skill, or clinical outcome. Clinical outcome is felt to be influenced by situated cognition theory, stating knowledge and cognition are integrated within a physician’s environment, and influenced by patient acuity and practice factors including clinical volume and changing technology.⁴

Figure 1. A, immediately after training, the perception of where you are now and need to be at the end of your career. B, reality of where you need to be based on the exponential growth of knowledge with time.

Patient care becomes more nonanalytical as we mature; we develop a greater confidence in our abilities, which results in an illusion of competence. This translates into greater errors and subsequent disciplinary action. Cognition and length of time in practice do parallel performance complaints, with physicians older than 70 years more likely referred for concerns of competence. On the contrary, physicians current in medical knowledge, regardless of age, decrease their risk of disciplinary action.^5–7 The illusion of competence and knowledge is described as the Dunning-Kruger effect; individually we can’t assess our own competence.⁸ Believing we are competent results in increased confidence and is often inversely associated with our true ability and skill. In other words, “we do not know what we do not know.” Autonomous nonanalytical patient care results in errors due to gaps in our knowledge and judgment, and continuously increases over time. We benefit from an outside entity helping us refocus and identify individual deficiencies.

To gain knowledge, particularly when focusing on a point-in-time exam or required activity, we ­often undertake binge learning. Most of us will successfully accomplish this goal; unfortunately the knowledge gained is quickly lost over time (Fig. 2). There is a science to successful learning that confirms binge learning is not durable, and self-study without a testing process does not result in sustained learning.⁹ To acquire, recall, apply, and retain knowledge, we must be repetitious; otherwise, learning is quickly forgotten. Testing does enhance ­learning, particularly when undertaken in a low-stake environment, utilizing frequent memory challenges.¹⁰ That technique strengthens the foundation of knowledge and embeds learning principles. There are several testing methodologies supportive of this philosophy. One of the more commonly utilized is “spaced” education, repeating similar low-stake tasks over time. Early foundational work in spaced education was undertaken in urology by B. Price Kerfoot.¹¹ Kerfoot randomized residents to a traditional or spaced education pathway when studying for the in-service exam. He found that both groups performed equally well on the exam, but when tested several months later, residents participating in spaced education maintained a significantly greater threshold of knowledge.

To gain and retain knowledge, a stepwise approach to lifelong learning allows for greater preservation over time (Fig. 3). Each step provides new exposure, raising contemporary knowledge. The tread of the step reinforces present and past knowledge, sustaining the learning experience.

Figure 2. A, how to gain knowledge? B, binge learning can achieve an immediate goal but will not be retained.

Figure 3. A “step” approach to gain and retain knowledge.

Figure 4. A strategy for successful lifelong learning (LLL).

A strategy for urological lifelong learning is founded in reinforcing our knowledge, exposing ourselves to contemporary advances, and ­assessing our knowledge gaps (Fig. 4). Accepting that we are not the best to determine our own lifelong learning needs; appreciating that repeated short activities keep our mind sharp and up-to-date; and understanding that periodic testing adds value to learning through reinforcement and identification of our knowledge gaps will help guide us to gain and maintain the knowledge needed to provide outstanding urological patient care.

Dr. Joseph serves as the Lifelong Learning Chair for the American Board of Urology.