Excellence and Failure

Everyone wants to succeed, but few people take the time to study excellence. Similarly, everyone dislikes failure, but few people invest the time and energy necessary to learn from their mistakes. Often we are too busy basking in the glory of our triumphs to think through what we did right, or the pain of failure is sufficiently intense that many of us want to "move on" and "put it behind us" as soon as we can. Yet those who want to improve their chances of excelling can ill afford to disregard the issue of why, despite seemingly equal levels of intelligence and education, some people tend to achieve at higher levels than others.

The standard curriculum is absolutely necessary if medical students, residents, and fellows are to develop into competent physicians, but it is not sufficient to enable them to reach their full professional potential. A substantial amount of educational research indicates that how learners understand excellence and failure exerts an important influence on their level of achievement. Medical educators would benefit from a better understanding of this influence.

This discussion outlines ten parameters that tend to distinguish high achievers from low achievers, based on differing understandings of excellence and failure. These parameters are loosely based on a school of thought in psychology frequently referred to as attribution theory. Although some factors in the larger equation of achievement may be difficult to alter substantially, each of us can revise our understanding of what makes a person excel. In doing so, we can enhance prospects for excellence both for ourselves and the people with whom we work.

The factors that contribute to or detract from excellence can be divided into two categories, extrinsic and intrinsic. Extrinsic factors flow from the decisions of others, and include their expectations, reactions of praise or blame, and their choice of how to reward or punish performance. Intrinsic factors, by contrast, arise from learners themselves, and include their expectations, their level of desire to excel, and their sense of whether they were challenged in a meaningful way. For example, learners tend to feel a greater sense of pride in their achievement if the task they face is a moderately difficult one, as opposed to one they regard as very easy. Therefore, it is important to present learners with tasks that challenge them but do not overwhelm them. If they feel that they never had a chance, or that they did not need to push themselves at all in order to excel, they are not likely to benefit significantly from the experience.

Different learning environments can dramatically alter how learners perceive their performance and what they expect of themselves. If people are confronted with tasks for which they have no means of preparing, they are less likely to feel pride in their work, even when they happen to excel. Because learners are more likely to fail in situations for which they are not prepared, the experience of continually confronting tasks for which they lack preparation is likely to produce discouragement. Daily case conferences that fail to differentiate between first-year and fourth-year residents would be a classic example of this error. By orienting tasks to learners' level of preparedness, educators can improve their overall sense of efficacy as learners. Too often, the challenges and assessments learners encounter are not gauged to their level of training, and a sense of disengagement from the learning environment is the result.

By indicating to learners what is expected of them in terms of planning and level of effort, educators can further enhance their sense of learning efficacy. The goal should be to give learners a sense that they are in control of their own destiny. Fostering this sense need not be difficult, and yet many programs forego opportunities to do so. For example, medical students and residents should be given a set of learning objectives each time they begin a new rotation, and day-to-day questions and assessments should be tailored to these materials. This is not to say that learners should never encounter things for which they are not prepared. Such encounters should be a daily occurrence, but some balance between the two should be maintained, so that learners find their studying reinforced with frequent opportunities to capitalize on what they are learning.

One of the traits shared in common by people who excel is a sense that they make things happen, as opposed to the feeling that things happen to them Learners who see the locus of control as lying outside themselves often see little correlation between their own choices and their level of achievement. When things go poorly, they blame it on bad luck, or on things other people did over which they have no control. By contrast, learners with a high sense of efficacy are likely to regard setbacks not as the immutable will of the fates, but as mistakes, from which they can learn and improve in the future. They study their experiences, failures as well as peak performances. Even when others contribute to their difficulties, they look for factors in situations over which they can exert some measure of control, and try to devise means to exploit them more effectively in the future.

Regarding the locus of control as internal does not, however, guarantee that a learner will react effectively to setbacks. Another key factor in how learners explain their successes and failures is whether they believe the internal factors are fixed or changeable. Learners who feel that their achievement accurately reflects who they are, and not external factors over which they exert no control, may nonetheless feel that their achievement is constrained by unalterable internal factors. For example, many learners regard ability as a natural endowment, something you either have or do not and can do nothing to change. Learners who interpret their failures as the result of their own intrinsic lack of ability are less likely to try to feel challenged by disappointments, and less likely to try to change their approach in the future. By contrast, effort is a changeable internal factor that the best learners attempt to improve.

People's explanations of how the world works and why things happen in their lives can provide great insight into their capabilities. The seminal approach asks people to recall personally meaningful peak performances or failures and to explain why things happened as they did. If a residency or faculty candidate responds to such a question with a look of befuddlement and cannot offer any coherent response, this is a good sign that they are not accustomed to reflecting on past experiences as learning opportunities. Similarly, if they portray themselves as innocent dupes or victims of forces beyond their control, this may indicate that they tend to experience events passively, rather than taking an active role in creating and influencing circumstances. Many people who excel, by contrast, tend to describe events as resulting from decisions they helped to make, and are likely to offer reflections on how they would do things differently in the future.

There is a difference between recognizing mistakes and labeling yourself a failure. In a sense, mistakes should be welcomed, because people who never make mistakes have ceased to innovate and learn. Rightly approached, mistakes are learning opportunities that constitute the stepping-stones to excellence. By contrast, labeling oneself a failure is likely to prove psychologically damaging and professionally debilitating. People who believe that they lack ability, that the tasks they face are too difficult, or that they have no control over the course of events in their lives are much more likely to consider themselves failures than people who interpret setbacks in terms of correctable deficits of understanding or effort. Perseverance, not genius, is the most characteristic trait of people who excel. In one of the most famous and briefest commencement addresses ever delivered,Winston Churchill encapsulated this lesson as follows,"Never give in. Never give in. Never. Never. Never. Never."

To say that people who excel tend to invite competition and unsuccessful people tend to shy away from it captures only part of the truth. There are two ways to win a competition. One is by choosing lesser opponents one can easily defeat. In choosing this path, people indicate that merely winning is more important to them than learning to perform at their best. By contrast, other people are primarily interested in doing the best they can, as well as helping others do their very best, and these people are likely to seek out challenges that force them to become better than they are. Comfort and fear of defeat can become enemies of human achievement, if they undermine the urge to take risks and push oneself to higher levels of performance. It can be tempting to attempt to insulate ourselves from competition in order to prevent the possibility of defeat, but people who give in to that temptation are consigning themselves to underachievement, and both they and their organizations are likely to suffer for it.

Three important characteristics of the learning environment that exert a huge effect on how learners set goals are the types of tasks they are assigned, the manner in which they are evaluated and rewarded, and the pattern by which responsibility is allocated. We need to assign learners tasks that challenge them at a level they can respond to and benefit from, neither too easy nor too difficult. We need to encourage learners to take risks, and to regard test scores and performance evaluations not as ends in themselves, but as means to the larger end of enhanced performance. If the only aspect of performance we ever acknowledge or reflect on is immediate triumph, then we may be encouraging people to sweep their mistakes under the carpet, and to forgo thinking about their work in a broader and more long-term perspective. Finally, we need to assign meaningful responsibility for learning to learners themselves, so that they become active and not merely passive inquirers. They should not require ongoing assignments from educators to continue to learn.

Some of the best contexts for learning defy our usual expectations as educators. We should encourage learners to work together in groups, with shared responsibility for learning. Such groups can be flexible rather than fixed, allowing members to come and go and to develop their own rules for learning. Because such groups can be small, they can tailor learning tasks to the knowledge level of individual members, creating a more efficient learning environment. They can turn the typically individualistic focus of medical education on its head, assigning learning tasks at the group level, thereby encouraging cooperation and mutual edification. They can provide truly substantive evaluations of what each member does and does not know and do so on a regular basis, rather than merely issuing a "report card" at the end of a few months or a year. Their goal is not to sort and rank learners, but to provide every member of the group an opportunity to learn. When they identify and correct mistakes, they do so in order to improve each member's understanding, not to determine who is the best. And they can ensure that each learner is an active participant who assumes responsibility for his or her own learning as well as that of every member of the group.

In order to achieve something, it is vitally important clearly to understand what one is trying to do. Learners who aim merely to avoid mistakes have sold themselves short. In such circumstances, learning becomes a byproduct of some other pursuit, and is likely to be less efficient and less effective. The best learners are the ones who seek out challenges and continue to question and grow throughout their careers. Just as learners need to understand what they are about in order to do their best, so educational programs need a clear vision of what they are trying to accomplish. By looking beyond the most immediate and easily measured parameters of performance and adopting a larger perspective that encompasses nonmedical factors of excellence, medical education programs can prepare their learners to excel at even higher levels.

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