Excelling as a Learner

If learners are to perform at their best and become the best physicians they are capable of being, it is important that we help them develop a clear vision of excellence in learning. Whether they be medical students, residents, fellows, or even practicing physicians participating in continuing medical education programs, we need to help them to see their target clearly if they are to hit it. In the case of medical students and residents, it is vital that no one regard their tenure in the training program as a period of indentured servitude, something that must be merely endured. Instead, learners gain more when they see their program as a learning opportunity designed to help them excel as learners.

The transition from medical school to residency can be particularly challenging in this regard. Throughout college and medical school, learners receive fairly clear performance expectations. They know that they want to earn high marks, and they know what level of performance is necessary to achieve them. Moreover, evaluations tend to be relatively frequent, because exams take place on a regular basis, and the results of tests are provided in relatively unequivocal terms: students' examinations are often scored numerically, and they receive grades of A, B, C, and so on. By tracking their performance over time, learners can determine whether they are doing a good job, and where necessary, take steps to improve their performance.

By contrast with premedical and medical education, many residency programs provide less clearly defined performance evaluations on a less-frequent basis. Residents may meet with their program director only several times per year, and the evaluations available may be relatively vague and offer little in the way of constructive suggestions for improvement. They may include comments such as, "Great attitude," or, "Needs to read more," which can be difficult to put into practice. Moreover, we should set our sights higher than mere competence. Competence is great, but excellence is an even worthier goal, and we should attempt to develop and articulate as clearly as possible a vision of excellent resident performance. Even if our loftiest aspirations are not achieved, their constant presence helps us perform at a higher level than we otherwise would.

To begin with, we need to dispel the enervating notion that the residents' primary goal is to survive their period of training, avoid catastrophic on-call mistakes, and prepare to pass their board examinations. Like passing a driver's test, achieving such minimal standards of performance is necessary to getting out on the road, but they do not prepare learners to flourish. Instead, they foster a lowest common denominator of performance, a desire to be merely good enough. If our learners are to thrive and achieve their full potential, we need to show them that they are capable of much more. They should aim to excel in the essential medical functions of diagnosis, consultation, and patient care, and to become the best physicians they are capable of being.

We spend thousands of hours teaching future physicians the knowledge and skills they will need to practice medicine. How many hours do we devote to developing our vision of medical excellence? This vision need not necessarily be articulated in writing, but it needs to be a frequent topic of conversation and reflection. How often do we highlight real-life examples of excellence in medicine, and how often do we take the time to discuss the sense of calling in medicine that underlies it? The goal is not so much to tell residents what their goal should be, but to encourage them to develop their own vision of medical excellence, and to evaluate their day-to-day performance in light of it. That being said, however, we should have our own vision in mind, and part of our work as educators should be sharing it with those we teach. Who are the best physicians we know, and what makes them so good? What about them would we most like to emulate, and what could we do to be more like them?

What follows is an outline of some of the general features that seem to characterize excellence among medical residents. What makes a really good resident, and what could we do to help other residents elevate their level of performance? Undoubtedly the list of characteristics would vary somewhat from educator to educator, and some might wish to add or subtract an item or two here or there, but this discussion can at least serve as a useful point of departure for this kind of conversation.

One obvious characteristic of excellent residents is a great fund of knowledge. In any training program in any specialty, the really great residents tend to know more than their colleagues. In part, they may have devoted more time and effort to reading in textbooks and journals. They may also pay more attention at teaching rounds and formal lectures. Yet the difference is not merely that they have more facts in their head. The key difference is that they are more adept at applying what they know in daily practice. When they attend a lecture, read a journal article, or discuss a case with a colleague, they are able to see how to apply that knowledge to patient care. They are able to contextualize new knowledge in such a way that it informs what they do. And it is not that they were born knowing more than everyone else. Instead, they manage to find and even create the most learning opportunities every day.

One misperception that may hamper many residents is the unrealistic view that they are supposed to know everything. If we expect ourselves to be perfect and tolerate only flawless performance, every day will be a devastating disappointment. Where knowledge is concerned, we should set high standards, but recognize that no one—not even the greatest physician who ever lived—knew everything. It is true that most great residents know more than their peers, but what really sets them apart is the importance of what they know and what they seek to learn. They are able to recognize what knowledge is more important, and to focus more of their attention on it. To some degree, standardized tests serve as a useful gauge of learning performance, but the needs of patient care, teaching, research, and service should be our ultimate guide in developing learning priorities.

Another fairly obvious characteristic of excellent residents is their skill in performing essential tasks of daily practice. Whether it be their adeptness at accessing and maintaining critical patient care information, organizing their workday, or performing a variety of diagnostic and therapeutic procedures, the best residents tend to be more skilled than their peers. Such skills are not only technical but also interpersonal. They are good at talking with patients and colleagues, and can be relied upon to convey information clearly and to do a good job of finding out what needs to be known. This is not to say, however, that they were born with such gifts. Their native manual dexterity is not necessarily superior to others'. They do, however, manifest a strong motivation to become their best, and this shows through over time in the great progress they are able to make.

Despite the great importance of both a resident's fund of knowledge and technical and interpersonal skills, other less frequently recognized characteristics tend to be equally important. The person who is chosen as chief resident is not always the one who knows the most or who displays the best performance at a particular skill. We are all familiar with residents who know more than their colleagues or who display the greatest manual dexterity, yet would never be chosen by their peers or faculty for a leadership position. If we are wise, we do not choose chief residents based strictly on their standardized test scores. Conversely, we know residents whose test scores were not the highest, yet whose overall performance would clearly win them the title of most valuable resident. What additional characteristics do such residents possess?

One such characteristic is clearly curiosity. The best residents are genuinely curious about their patients and the practice of medicine, and they treat every day as a valuable learning opportunity. The best residents may not have known more than everyone else on the first day, but they manage to wring more new insights from their work than others. Simply put, they love to learn. This love of learning manifests itself not only in their reading, but in the questions they put to patients, colleagues, and faculty. And when they learn, they are not merely collecting and cataloging facts, by seeking to understand the "How?" and "Why?" of new knowledge.

It is important that faculty members not respond to this inquisitiveness defensively. A resident who asks a lot of good questions make take more of a faculty member's time and even reveal more of the holes in the faculty member's understanding, but this deeper level of understanding will pay big dividends in terms of what excellent residents can contribute. To work with residents who really care about learning can be one of the most rewarding experiences of a medical educator, in part because it stimulates even the most accomplished among us to continue to learn and grow.

Another characteristic of great residents is their approach to errors. In the past, some programs treated errors as embarrassments that should be kept hidden, because the consequences of having an error brought to light are so dire. People whose errors were found out were either humiliated, reprimanded, or disciplined in such a way that no one wanted anyone else to know they had made a mistake. In such a culture, residents learn not to discuss or even admit their mistakes, and as a result, important opportunities to learn are lost. In an optimal learning environment, we would recognize that errors provide important learning opportunities, and seek to handle error in such a way that everyone can benefit from one another's mistakes.

It is misleading to suppose that the best residents are perfect and never make mistakes. Everyone makes mistakes. The difference between excellent residents and their peers is that the best residents make the most of their own mistakes and those of others, and put their lessons to use in improving their own approach to practice. Such mistakes range from medication errors to failure to follow up on diagnostic testing to allowing frustration or anger to interfere with professional interactions and patient care. When an error occurs, the best residents ask questions. Why did this happen? What can we learn from this mistake about our current practices? What can we do to prevent this sort of error from recurring in the future? Does this point to any broader changes we should make in the way we train residents?

Another characteristic of excellent residents is conscientiousness. Conscientiousness means more than merely working hard. It means responding to work in a certain way. Some residents attempt to get their work done as quickly as possible, with the least expenditure of effort. In some cases, this may even lead to cutting corners. This approach tends to promote preventable errors, such as failures to detect abnormalities on physical exams or to plan appropriately for patient discharge from the hospital. Other residents work very hard, but do so inefficiently, so that they work extra hours and are prone to exhausting themselves. They may be so obsessive about checking and rechecking everything that they cannot handle as much responsibility as their peers. Some residents, in other words, may prefer to do as little work as possible, and others may have difficulty discerning the appropriate amount of effort to devote to a particular objective.

Between these two extremes is a happy medium, a resident who is both effective and efficient in the use of time and who sincerely enjoys doing a good job for patients and colleagues. When we sincerely enjoy doing a good job, we are more inclined to immerse ourselves in the work for its own sake, not merely because we are afraid of getting into trouble. Those who don't enjoy the work of patient care may feel that they are merely punching a clock, working for the weekend, and this attitude shines through in the quality of their work. By contrast, those who cannot recognize when enough is enough do not really understand what they are working on, and so cannot feel comfortable that they have accomplished their mission and can move on. The best form of conscientiousness is not the result of flogging by the superego. It flows from sincere joy and pride in the work we do.

The best residents also demonstrate a high degree of personal initiative. They are not merely trying to avoid making mistakes. They are looking for opportunities to make their service run more smoothly. If they see an opportunity to contribute in some way, they seize it. If there is work to be done, they tend to volunteer to do it, in part because they enjoy helping their team to achieve its mission, and in part because they see new challenges as important learning opportunities. If there is something they need to be doing, they are less likely than others to need to be told to do it. When they are asked to do something, they set about getting it done with gusto.

Taking initiative means more than merely delivering on a job description. Great residents do what they are required to do and do it well, but are on the lookout to do more. For example, if they see a great case, they are likely to write it up for presentation or publication. If they realize that the curriculum on a particular rotation could be improved, they take the initiative to suggest changes, and to help bring those changes about. Left to their own devices, they tend to improve the programs of which they are a part. They see the program not merely as a springboard to their own success, but as an organization to whose mission they are committed, and to which they can make an important contribution.

Another related characteristic of excellent residents is reliability. When someone asks a great resident to tend to something, they can be relied upon to see that it gets done. This reliability manifests itself in both obvious and not so obvious ways. In obvious terms, it means that great residents show up for work on time, stay till the work gets done, and can be counted on to be where they are supposed to be. In less obvious terms, this reliability shines through in the everyday tasks of medical practice. The best residents obtain their own histories, make sure that all the laboratory results are checked every day, follow up with patients, never cut corners in collecting or analyzing data, and prepare thoroughly for new challenges. Not only faculty but fellow residents, medical students, and other allied health personnel have confidence in reliable residents.

Great residents are also generally affable people. They need not be the most popular people in their programs or the life of the party at social functions. They need not be the best-looking or best-dressed. They do, however, tend to be well liked by most everyone, because they treat people fairly and respectfully, and manifest a genuine interest in their well being. Such residents talk with others, and know what is going on in others' lives. They know who is getting engaged to be married, or who has a baby on the way. They also know who is having difficulties, and do what they can to help. Above all, they treat everyone they work with as human beings. They do not have one standard of conduct for their superiors and another standard for those below them on the ladder of authority.

A characteristic of many though not all excellent residents is their range of interests and responsibilities outside medicine. Many have unusual life experiences, wider professional backgrounds, or special extracurricular interests. Some bring past work experience in such areas as entrepreneurship, teaching, or information technology, which enriches their medical work. Others bring a certain intellectual maturity and balance to their work because of outside avocations, such as dance, woodworking, religious service, or coaching a youth athletic team or leading a scout troop. Family life, especially marriage and parenthood, may contribute to professional maturity, as well. Having children of their own enables some residents to view day-to-day challenges from a somewhat larger perspective that makes difficulties seem a bit less overwhelming.

Above all, excellent residents manifest admirable character. They are honest, unselfish, and genuinely understanding of others. In an important sociological study of residency training, Charles Bosk identified two types of resident errors: technical and normative. Technical errors, such as missing a physical examination finding or failing to prescribe the appropriate medication, are generally forgiven, as long as the resident makes an effort to learn from them. Normative errors, by contrast, include lack of dedication and frank dishonesty. These sorts of errors are not easily forgiven, because they indicate a deficiency not only of knowledge or skill, but of character. Great residents are, above all, people we can trust to do what is right.

In sum, it is by helping faculty and especially residents develop a clearer and more complete vision of excellence in residency that we can best prepare residents to excel. This is our target, and only by clearly seeing our target are we prepared to hit it. Once we define such a vision,we can use it to guide our growth and development not only during residency but throughout our careers,because the characteristics of great residents are also the characteristics of great physicians.

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