Most of us would like to excel at what we do, but few of us have devoted much time and energy to the study of excellence. Similarly, we want to avoid failure, but most of us do not learn as much as we could from our disappointments. Often we are too relieved or even exulted in our successes to step back and think through what we did right, and the pain of failure may be so great that we simply want to put it behind us as soon as possible. Yet if our learners are going to improve their performance, it is important that we foster reflection on the question of why, despite equal levels of intelligence and experience, some people perform at a high level and other people perform relatively poorly.
A wealth of educational research indicates that our very ideas of what constitutes success and failure differ widely, and that these differing understandings powerfully influence our level of achievement. In what respects do high achievers differ from low achievers? Some of the most important distinguishing features have been elucidated by a group of psychologists developing what has come to be called attribution theory. There are some learner attitudes and perceptions we cannot change,but there are others that we can revise, and doing so can help learners such as medical students, residents, and practicing physicians perform at a higher level.
The factors that either enhance or detract from high performance can be divided into two categories, extrinsic and intrinsic. Extrinsic factors concern decisions made by people other than learners themselves, such as faculty members. These include expectations, reactions of praise or blame, and rewards or punishments. Do we expect learners to perform well or poorly? Do we offer frequent praise when learners perform well, or do we simply withhold blame? Do we lead primarily with a carrot or with a stick? Intrinsic factors pertain to learners themselves, and include their expectations, their level of motivation to perform at their best, and the level of challenge they experience in learning.
We tend to feel relatively little sense of accomplishment if our learning tasks do not challenge us in any meaningful way. By contrast, a high sense of achievement may flow from a moderately difficult task, one that demands our full concentration and effort. If learners are to perform at their best, it is important that they approach learning tasks with at least a moderately high level of intrinsic engagement and a reasonably high expectation of success. If they see no importance to what they are learning, or if they think they have little chance of success in learning it, they are unlikely to perform at their best.
Thus we need to challenge learners but not overwhelm them. If they feel they never had a chance or did not need to make an effort, the learning experience is likely to provide little benefit. In educating medical students, for example, we need to ensure that we tailor learning tasks to their particular level. What can a second-year medical student be expected to know, and how does it differ from what a fourth-year student knows? If we pay close attention to learners, the same clinical case that helps to reinforce important anatomical and physiological principles for a second-year student can also help a fourth-year student consolidate important diagnostic and therapeutic principles. This can only work, however, if we know the learners, and operate with appropriate expectations.
Learning environments can powerfully influence learners' expectations for themselves, as well as how they appraise their own performance. If we are confronted with learning tasks for which we lack the means to prepare, we are less likely to feel proud of the work we have done, even if we happen to succeed. Our probability of success declines when we lack preparation, and confronting learners with questions they cannot know the answer to can leave them feeling discouraged and undermine their motivation to learn. We can apply this principle in teaching by structuring learning experiences in such a way that learners can easily see the relevance of what they already know to the learning task at hand.
We can, for example, help medical students and residents become more effective clinical consultants by presenting them with situations where they are asked to interact with colleagues in formulating diagnostic and therapeutic plans for patients. From the first days of medical school, students can be asked to think in terms of what they would recommend for a particular patient. In the beginning, questions can focus more on what additional information they need and how they would go about acquiring it, and as they progress, they can be asked to use what they know to choose between different available options for diagnostic testing and the like. In this manner, students do not feel so unprepared when they begin to care for real patients.
We can further enhance learner effectiveness by making clear the level of effort we expect. The goal is to provide learners a sense that they enjoy substantial control over their own educational destiny. Do we provide medical students and residents realistic sets of learning objectives, and do we tailor daily teaching and assessment to them? It is no use setting expectations so low that no one could ever fail. But they do need to be explicit enough that learners are able to discern not only what they should be studying but also what they should be able to do with what they are learning. A good example is the way we teach cardiopulmonary resuscitation, where we not only expect learners to pass a written exam, but to actually perform each of the maneuvers.
If we want to perform better, we need to develop a sense that we can make things happen, as opposed to the sense that things merely happen to us. The key is the locus of control. Learners who see the locus of control as lying outside themselves are much less likely to see a strong connection between the choices they make and their level of performance. When things do not go as expected, they blame it on forces over which they have no control, such as bad luck or the failures of others. By contrast, learners who exhibit a high sense of personal efficacy are likely to regard setbacks not as the work of some inscrutable and malign outside force, but as their own mistakes from which they can learn and improve in the future. Such learners study their experiences, both failures and successes, to determine what they could do differently. They recognize that they are not in complete control, but they seek out those aspects that they can influence and try to influence them more positively in the future.
One means of fostering this kind of self-awareness among learners is the so-called critical incident approach. How does it work? At the conclusion of a learning task, learners are asked to reflect on their performance and to determine why they performed as they did. If our organizations are to perform at their best, we need to attract people who are accustomed to reflecting on and learning from their experiences. If we ask a candidate to tell the story of one of their greatest successes or failures and they cannot think of one, that is a bad sign. The same is true if they have no idea why things turned out as they did, or if they keep attributing the result to external forces. We want learners to see themselves not as victims, but as co-creators of their own level of excellence.
To foster this kind of self-awareness, we need to encourage learners to step back and reflect on their performance, and to develop the habit of doing so on a regular basis. How often do we sit down with medical students or residents and ask them to tell the story of one of their biggest successes or failures? Why did it turn out that way? What could they do differently in the future to improve the result? If learners do not spend at least part of their time reflecting on their own performance, looking into the mirror, so to speak, they will be less well equipped to learn from their practice and continue to improve in the future.
It is not enough, however, merely to regard the locus of control as internal. It is equally important whether we see the internal factors as fixed or alterable. An internal factor that many of us tend to regard as fixed is innate ability. It is sad but true that many young people develop low expectations of themselves as a result of just a few disappointments. For example, students suppose that they just can't do math, or they lack the manual dexterity necessary to become a surgeon. In short, they develop a "can't do" attitude, supposing that they must have been absent on the day a particular ability was distributed. Learners who interpret their poor performance in terms of their own intrinsic lack of ability are much less likely than others to feel challenged by disappointments or to make efforts to change their approach in the future. Instead, they are likely simply to give up. This is not to say that each of us does not have limitations. However, we should not be so quick to invoke our limitations as the explanation for our disappointing performances.
We need to encourage learners to shift their focus from ability to effort. When we fail, we can either say, "I am just not good at this," or we can say, "I wonder what I could have done differently." If the goal is to foster the attitude that obstacles can be overcome and to improve, then we need to foster the latter perspective. The question is not,"What am I capable of?"but,"How can I make an even stronger effort?" Do we as educators regard students' performance primarily as an indicator of how smart they are, or as an indicator of their level of effort? Insofar as possible, we should attempt to think in terms of effort, because our attitudes may powerfully influence how learners come to think themselves.
What is our attitude toward mistakes? Do we see every error as a sign that we are failures, or do we see it as a learning opportunity? People who never make mistakes have ceased to learn, and unless we can claim to know everything, none of us can afford to stop learning. Every error can be a stepping-stone to excellence, by helping us better discern what works. By contrast, labeling ourselves as failures just makes us even less likely to perform well in the future. Learners who believe they lack ability, that the challenges before them are simply too difficult,or that they have no control over their own destiny are much more likely to consider themselves failures than people who interpret setbacks as learning opportunities.
As Thomas Edison repeatedly emphasized, perseverance is a more constant feature of high achievers than genius. Medical students and residents are accustomed to thinking of themselves as bright people, and expect to succeed. In some cases, a disappointing performance may leave them at a loss. When that happens we cannot afford to act mules, who merely keep trying the same thing over and over again, only harder. Insanity was once defined as the expectation of deriving different results from doing the same thing. In contrast to the mule, when the fox fails, he changes his approach and does something different. Effort is not merely bull-headedness, but the wealth of experience and ingenuity that lies at our disposal.
Many features of medical education tend to discourage this attitude. For example, our written examinations generally emphasize conformity. There is one right answer, and it is the same right answer for every learner. We reward memorization and recall. Not only does this discourage the attitudes of skepticism and creativity on which the future of medicine depend, but it also tends to undermine learners' capacity to respond effectively to setbacks. Winston Churchill performed poorly in subjects such as mathematics, and graduated near the bottom of his class in secondary school. He always knew, however, that he had a greater destiny in life, and despite his parents' and teachers' despair, he kept doing what seemed important to him. Eventually, his efforts paid off, and he became one of the most important political leaders of the twentieth century and won a Nobel Prize in literature.
Churchill's story reminds us of the importance of risk taking. Victory alone is not what is most important. What is most important is performing at our best, and making the best contribution we can. If we restrict ourselves to challenges we can easily overcome, we are unlikely to improve. By contrast, if we want to become our best, we need to choose meaningful challenges, to take risks, and to accept the possibility of failure and defeat. Playing it safe is a recipe for indolence and mediocrity. The best leaders are those who encourage not only themselves but those around them to strive beyond what we are certain we are capable of.
What risks could medical students take? Here are some ideas. Find a question in medicine to which no one knows the answer and develop a plan to answer it. Develop a lesson to teach colleagues about a key concept in medicine. Take a course in a nonmedical subject, such as history, philosophy, or art. Draft a one- to two-page critique of a class you are taking with suggestions for improvement, and share it with the instructor. Write brief biographical sketches of a dozen of your colleagues. Spend a month helping to deliver healthcare in a foreign country. Such experiences are important not merely in their own right, but because they encourage learners to begin to think in broader terms about the challenges open to them.
If we are going to perform at our best, we need to clearly understand what we are trying to do. If our aim is merely to avoid mistakes, we are selling short both ourselves and our profession. The best learners are those who seek out challenges and continue to question and grow throughout their careers. We need to look beyond the content of our textbooks and consider the effects of our educational programs on learners' habits and self-perceptions. All of us are capable of more than we think, and if we recognize what is necessary to unlock more of that potential, we can perform at a higher level of excellence.
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