Have you ever felt so stupid, and yet so happy to be stupid, at the same time? That was me at the USSONAR Multi-Track Conference earlier this year. Long-time readers may know that I have a particular affinity for ultrasound and, through hard work and diligent practice, I believed that I excelled at it. However, sitting in the audience, I felt incredibly humbled. Even with all the hours of learning, scanning and teaching over the years, I was nothing compared to the true masters of ultrasound, the people who scrutinize and find value in every pixel on the screen.
Strangely enough, that feeling of inadequacy wasn’t discouraging. On the contrary, it was energizing and highly motivating. To be surrounded by individuals who had pushed themselves to become masters, to listen to their wise words and to learn from them felt like an immense privilege. As I was returning home with a head chock-full of new information and imagination for what could be done with ultrasound, I was struck by a more concrete thought. Mastery is not merely an end point; it is an evolving set of relationships between knowledge, curiosity and humility.
The value in ultrasonography is only revealed once the enormity of the clinician’s prior experience is put on display. After all, ultrasound is not merely the art of obtaining a technically adequate picture on a screen. It’s about condensing that complexity of information into actionable clinical information. Additionally, in the context of rheumatology, it is about integrating other sources of information, such as the history, the physical examination, laboratory findings and other radiographic data.
In this way, revelation has both visible and invisible dimensions. Outwardly, we see pathology, like an effusion, an erosion or tenosynovitis. That’s the aha moment, when something comes into view and our pupils suddenly snap to attention at a detail. Less evidently, we can catch a glimpse of the clinician’s precision, patience and perspective in the background observations of intense muscle memory and dexterity with a probe, fast fingers adjusting knobs and judicious use of dynamic procedures. When you appreciate both these external and internal dimensions, you start to recognize that the image on screen becomes a mirror to the clinician-patient interaction.
Moreover, the art of revelation is inherently narrative. Just like the adage, “A picture is worth a thousand words,” each ultrasound image is a novella in its own right. Each scan speaks of the majesty of billions of years of evolutionary biology and provides glimpses into the unpredictable world of pathology. Within the context of the patient’s illness, it provides affirmation of their signs and symptoms as well as opportunities for management and relief. True masters are able to appreciate the subtlety of these details and anticipate the plot lines.
Finally, ultrasonography demands trust. The patient entrusts the rheumatologist to reveal something about themselves. In turn, the rheumatologist using ultrasound must trust their own perception and training. This multifaceted aspect of trust forms the bedrock upon which clinical insight is built, and masters wield this trust to great effect.
Deliberate Practice
In truth, revelation is only the beginning of mastery. For true mastery, revelation must be followed by the discipline of doing the work with deliberate practice. In other words, it is not enough to passively accumulate experience or perform tasks by rote. Mastery demands mindful repetition, targeted improvement and constant feedback and, in the process, pushing oneself beyond the comfort of safety and familiarity into the discomfort of growth.
As clinician educators define it, deliberate practice is purposeful and systematic.1 It targets specific skills, stretches one’s current limits and promotes active reflection. Within the world of musculoskeletal ultrasonography, that means fine-tuning probe pressure, experimenting with different scanning angles and integrating sonographic findings into clinical reasoning.
Let me give you two examples of this, which I witnessed while I was at the conference. I was taken aback by the commitment of many participants with whom I interacted. There were two in particular who demonstrated how deliberate practice is operationalized in different contexts. The first participant was Joel Wright, a rheumatology fellow at the University of California, Los Angeles. In talking with Joel, I realized he was a highly precocious second-year fellow who spent much of his first year engaging in deliberate practice for musculoskeletal ultrasonography. He seeks a career in which ultrasonography is front and center. The second was Vandana Sharma, a rheumatologist in private practice in California. Unlike Joel, she is in the last years of her rheumatology career, yet she decided she wanted a new challenge and took up ultrasonography with great enthusiasm.
In both cases, I noticed how deliberate practice was transforming their habits into expertise. When I discussed with them the practical challenges of musculoskeletal ultrasonography, they relayed that it is not simply about scanning hundreds of joints, but about scanning each one with feedback, reflection and refinement. Joel and Vandana showed me that no matter the stage of career, the principles of mastery remain the same: sustained effort, honest self-assessment and an insatiable hunger for growth. They both practiced with intense intention, critique and adaptation.
Interestingly, their contrasting trajectories underscore another key feature of mastery—its independence from age or status. Mastery may seem like an old-fashioned, class-based term but mastery is, at its root, democratic. Mastery doesn’t reward tenure inasmuch as tenacity. Joel’s youth did not disqualify him from striving for greatness, just as Vandana’s seasoned career did not preclude reinvention. In both cases, their journeys emphasize that expertise is available to anyone willing to work for it, regardless of background, schedule or starting point. We all start as novices and, so long as we have the motivation, we can all—under the right circumstances, of course—become masters.
Mastery & Humility
That brings us to the paradox of mastery and humility. When I had talked with the master sonographers, they didn’t see themselves as anything special. Moreover, they almost preternaturally pivoted to talking about the frontiers of ultrasound in rheumatology, and excitedly talked about how they could become more fluent in that.
As far as I could tell, these displays of humility were not expressions of false modesty but instead a recognition of the vastness of the unknown. There is always another master to look up to and, probably, even the master of masters (the final boss) is looking up to their future self. The horizon keeps on expanding and with it, so too does the master’s sense of wonder. This kind of humility is self-replicative.
This humility also bleeds into curiosity. The masters I met were the most inquisitive, asking questions about emerging technologies, novel protocols and freely admitting mistakes that they had committed in the past. They were not threatened by the new but energized by the possibilities for the future. Dr. Wolfgang Schmidt, who first described the halo sign in giant cell arteritis, exemplified this by excitedly bringing up questions about how newer vascular ultrasound modalities may revolutionize our care of vasculitis.
Perhaps most beautifully, humility breeds generosity. The masters didn’t need to be there. They probably could have made a fortune elsewhere, but they chose to teach, share tricks and guide hands. They demonstrated how mastery is a gift to share with the rest of the world.
Maintaining Balance
I would be remiss without discussing the darker side of mastery. Time and effort are essential toward mastery, and so sacrifice is inevitable. In the process of deliberate practice, it’s impossible to ignore the cost that comes with forgoing other opportunities. Would becoming a master at musculoskeletal ultrasound mean giving up another element of being an excellent rheumatologist—or physician, for that matter? Could it risk crowding out other skills or unintentionally diminish attention to the human side of care? Might we neglect the parts of ourselves that find purpose and meaning in teaching, research or even hobbies outside of medicine? These are difficult questions we must ask on our journey toward mastery.
In my opinion, the danger lies in over-identification. When mastery becomes the sole axis of identity, imbalance logically follows. Relationships can fray, health can suffer, and the joy of the broader practice may erode. A fixation on perfection as the mark of mastery can crowd out curiosity. Similarly, a hyper focus on performance may leave little space for experimental play. Zealotry in becoming a master can even lead to guilt when we fall short, or envy when others succeed. It can isolate us from even our innermost selves. These risks don’t invalidate the pursuit of mastery, but they do highlight the need for intentional reflection to complete deliberate practice.
Sustainable mastery also entails boundary setting. It means reserving space for rest, for relationships, for just plain randomness. The rheumatologist who takes time to paint or play or parent may return to the clinic with greater depth and insights. Contrary to our images of scientists burning the midnight oil and athletes self-flagellating themselves for performance, balance is not the enemy of mastery. Prioritizing sleep, delegating tasks and saying no to unnecessary obligations are acts of sustenance in the journey toward mastery. More importantly, connecting with peers can remind us that the path of mastery is best walked together.
Conclusion
Suffice to say, I left the conference, as I leave most conferences, both awestruck and inspired. Yes, I felt the sting of inadequacy, but also the thrill of possibility. The people I met, masters and novices alike, reminded me that mastery is not a finish line but a Zen-like mindset.
In that conference room, surrounded by people who made pixels speak like poetry, I remembered what it felt like to be a total beginner again. That sense of excitement that came with placing a probe on skin and magically seeing bones and tendons and blood vessels came rushing back to me. Beyond the complex relationships between deliberate practice, relentless curiosity and maintaining balance, perhaps that’s the key aspect of mastery: It loops and builds back on itself. The master becomes the student, and the student becomes the master. The revelation never ends.
Bharat Kumar, MD, MME, FACP, FAAAAI, RhMSUS, is the director of the rheumatology fellowship training program at the University of Iowa, Iowa City, and the physician editor of The Rheumatologist. Follow him on X (formerly Twitter) @BharatKumarMD.
Reference
- McGaghie WC, Barsuk JH, Wayne DB, Issenberg SB. Powerful medical education improves health care quality and return on investment. Med Teach. 2024 Jan;46(1):46–58.
