The Power of Three

One, two… three. Have you ever noticed the curiosity of three? From concepts to differentials, when it hits three, the mind receives. Hit four or more and many, like us, just tend to forget. The phenomenon of three permeates our everyday life. From branches of government to marketing slogans (“Just do it!” and “I’m lovin it!”)¹, three strikes a trifecta of balance, completeness and remembrance. Three is even more important to us because it drives the mission of the academic surgeon (aka the “triple-threat” surgeon). In this article, we hope to convey to you the power of three and to encourage adoption, or at least recognition, of this technique in your everyday practice.

Behavioral research offers ample evidence that the power of three exists. In one study, researchers tested how impressions varied about products depending on the number of persuasive claims made to a group of participants.² Not surprisingly, the participants’ impressions improved with each additional claim, but only to a point. Beyond three claims, impressions decreased, likely due to new levels of skepticism. Other studies have shown that three events are quintessential for the perception of a streak which can then influence our actions.³ In the art of persuasion, more or less is not always better. Three is key.

From marketing and business to religion and politics, the power of three applies in medicine. For the academic surgeon, this number is particularly useful in each of our three missions.

1. In our research mission, the rule of three frames many of our approaches to problems and ways of communication. In health disparities, for example, a conceptual framework of three (identify, understand and reduce) helps guide research.⁴ In grant-writing, we often adhere to a maximum of three specific aims. Similarly, when we are planning a presentation, the adage that “complexity is the enemy of clarity” applies and we find ourselves editing down, and sizing up, the 10-point font sentences crammed onto each slide. More recently, the power of three is seen in the influential concept of the visual abstract, which is framed by a key question, the results and the citation.⁵ In research and information transfer, there is beauty in simplicity.

2. In our education mission, the rule of three creates structure and guides the many ways of teaching. For technical tasks, many still pay homage to the surgical philosophy of “see one, do one, teach one”. In learning, triads (like Charcot, Beck and Virchow) organize complex disease processes. In teaching, students learn better not with a list of 10 differentials or management steps, but by categories or themes of three. Even in surgical hierarchies, we often organize teams by threes: an intern, a junior, and a senior to cover the spectrum of skills and learning levels. In education, three fits well with its penchant for balance, completeness and remembrance.

3. In our clinical mission, the adage of three again applies. One of our mentors often shares the three keys for success for the young surgeon starting his/her practice: be available, be affable, and have ability (in that order).⁶ At another level, an outstanding practice depends on great teams in the clinic, operating room and wards. It also boils down to taking care of the patient in every part of the three-part surgical journey. Three even guides our way of thinking about quality of care: Donabedian broke the concept into distinct domains of structure, process, and outcome.⁷ In all these examples, the use of three provides a memorable and understandable way to position for success in our clinical mission.

The rule of three is not perfect, however. Some technical skills may be best taught in four phases: see one, simulate one, do one, teach one. Many tenure committees look for two, not three, areas of academic excellence. Abdominal pain has more than three surgical etiologies. The rule of three, while successful in many areas, cannot be forced in all situations. But what it offers is a starting point and an easy-to-use mechanism by which we can strengthen our writing, improve our teaching and advance each of our academic missions.

Embrace the power of three – look carefully, and you will find it all around you.

REFERENCES

1. Rucker JD. Slogans that stick: Why “Three. Words. Rule.” Available at: http://soshable.com/best-3-word-slogans/. Accessed December 23rd, 2016.
2. Shu SB, Carlson, K.A. When Three Charms but Four Alarms: Identifying the Optimal Number of Claims in Persuasion Settings. Journal of Marketing. 2014; 78:127-139.
3. Carlson KAS, S.B. The rule of three: How the third event signals the emergence of a streak. Organizational Behavior and Human Decision Processes. 2007; 104:113-121.
4. Kilbourne AM, Switzer G, Hyman K, et al. Advancing health disparities research within the health care system: a conceptual framework. Am J Public Health. 2006; 96:2113-21.
5. Ibrahim AM. Components of an Effective Visual Abstract. Available at: https://http://www.surgeryredesign.com/. Accessed December 23, 2017.
6. Hawn MT. Key to Success: Learn from Failure! University of Alabama at Birmingham, Department of Surgery Grand Rounds. Birmingham, AL, 2015.
7. Friedman MA. Issues in Measuring and Improving Health Care Quality. Health Care Financ Rev. 1995; 16:1-13.