- Richard B. Gunderman, MD, PhD
Never give in. Never give in. Never give in. Never. Never. Never. Never.
—Winston Churchill (1)
Everyone wants to succeed, but few people take the time to study success. 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 success can ill afford to disregard the issue of why; despite seemingly equal levels of intelligence and education, some people succeed where others fail.
A substantial amount of educational research indicates that how learners understand success and failure exerts an important influence on their level of achievement (2). In this editorial, I outline several parameters according to which high achievers tend to differ from low achievers. These parameters are derived in part from a psychologic approach to motivation and performance referred to as attribution theory (3). While some factors in the larger equation of achievement may be difficult to alter, each of us can revisit and perhaps revise our understanding of what makes a person successful. In so doing, we can help learners such as medical students, residents, fellows, and even practicing radiologists enhance their opportunities for success.
Intrinsic and Extrinsic Factors
The factors that contribute to or detract from success can be assigned into two categories, extrinsic and intrinsic (4). Extrinsic factors flow from decisions made by people other than learners and include their expectations, reactions of praise or blame, and any rewards or punishments they may offer. Intrinsic factors, by contrast, arise from learners themselves and include their expectations, their level of desire to succeed, and their sense of whether or not 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 that they regard as very easy. Learning effectiveness is enhanced when learners approach tasks with a high degree of intrinsic engagement and a reasonable expectation that they will perform well.
It is important to present learners with tasks that challenge 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 succeed, they are not likely to benefit substantially from the experience. In medical student education, for example, it is important to operate from a clear sense of what students at each particular level of training might be expected to know and to tailor learning tasks accordingly. For example, in a course for 2nd-year medical students, discussions of imaging findings might include questions about key points of anatomy and pathology. In reviewing the same case with 4th-year students, by contrast, greater emphasis might be placed on the clinical setting in which the examination was performed and the management implications of the findings.
Enabling and Disabling Learning Environments
Different learning environments can dramatically alter what learners expect of themselves, as well as how they evaluate their performance. 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 succeed (5). Because learners are more likely to fail in situations for which they lack preparation, confronting learners with questions for which they are not prepared can prove counterproductive, producing discouragement and reducing the motivation to learn. To put this principle into practice, educators should structure learning experiences in such a way that learners recognize the relevance of their own preparation.
A good example of tailoring the learning environment to foster a sense of preparedness is the use of an environment that approximates the actual setting of the American Board of Radiology oral examination in helping residents to prepare for the oral board examination. If residents have never before been shown cases in a setting where the examiner provides no feedback about performance, they may find the actual examination unfamiliar and unsettling and, hence, perform below their potential. Residents should be encouraged to show one another cases and they should be shown cases by the faculty in a no-feedback environment so that they will not be accustomed to looking for clues from their examiner on how they are doing. At another level, having board examiners pretend to be referring physicians can be helpful as well, by encouraging residents to develop their facility at discussing cases in the environment where it matters most; namely, the care of real patients.
High Expectations and Low Expectations
By indicating to learners the level of effort that is expected from them, educators can further enhance their sense of learning effectiveness. The goal should be to give learners a sense that they are in control of their own destiny. Fostering this sense of self-reliance is not difficult, and yet many educators forego opportunities to do so. For example, medical students and residents should be given a set of performance objectives each time they begin a new rotation, and day-to-day teaching and assessment should be tailored to them.
Expectations need not be low, but they should be as explicit as possible so that learners know not only what they should study but also what they should be able to do with what they have learned.
Consider a group of 1st-year residents undergoing an orientation to the radiology residency program. One objective of such an orientation program might be that residents develop the ability to recognize and appropriately manage an adverse reaction to intravenously administered contrast material. In order to set the appropriate expectations, they might be told that they will receive not only a lecture on the subject with a set of readings but also an objective structured clinical examination in which various types of adverse reactions would be simulated. With such expectations in mind, they would be able to prepare in a much more focused fashion, paying dividends in terms of their actual level of clinical competence.
Active and Passive Responsibility
One of the traits shared in common by successful people is a sense that they make things happen, as opposed to the sense that things happen to them (6). The key parameter here is the locus of control.
Learners who view the locus of control as lying outside of themselves often see little correlation between the choices they make and their level of achievement. When things go poorly, they blame it on bad luck or on actions of others over which they have no control. By contrast, learners with a high sense of effectiveness 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 successes. 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.
With the critical incident approach, people are asked to recall personally meaningful successes or failures and to explain why things turned out as they did (7). Such an approach can prove very helpful in attempting to evaluate and rank candidates for a position. If residency or faculty candidates respond 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. Successful people, by contrast, characteristically tend to describe events as flowing from decisions they helped to make and are likely to offer reflections on how they would do things differently in the future.
How can learners be encouraged to relocate their locus of control within themselves? One means of doing so is by engaging in regular discussions about setbacks and difficulties that they have confronted and how they understood and responded to them. For example, when residency program directors meet with each trainee, they might encourage them to discuss a recent disappointment or failure. What happened? Why did it happen? What could the resident have done to prevent or alter the undesirable outcome? What steps could the resident take to make such outcomes less likely in the future? When learners do not spend at least part of the time looking into the mirror, they miss out on opportunities to learn and grow.
Unalterable and Alterable Factors
Regarding the locus of control as internal does not, however, guarantee that a learner will react effectively to setbacks. Another key factor in how people explain their successes and failures is whether they believe internal factors are fixed or changeable. A common example of an internal factor that many people regard as unalterable is ability. As a result of a few disappointments early in their educational careers, some people adopt a “can’t do” attitude: “I’m just not good in math” or “I have good ideas but I can’t get them onto paper.” Learners who interpret their failures as resulting from their own intrinsic lack of ability are less likely to feel challenged by disappointments and less likely to try to change their approach in the future. Of course, every learner at every level of ability has innate limitations. The problem with invoking those limitations as an explanation for failure is the fact that many learners do so prematurely and with excessive frequency.
If the educator’s goal is to help learners improve their level of performance, then shifting their focus from ability to effort can prove very helpful. Consider a junior faculty member who is disappointed by the student evaluations of his or her teaching. One approach to such a situation would be to say, “I’m just not a good teacher, so of course my evaluations are not very good. They should find someone else to teach this course.”
A more helpful approach would be to study the student evaluations to determine the source of the poor evaluations. Do students feel that the teaching is not tailored to their level of understanding? Do they feel that a more interactive approach would be helpful? Could a more senior faculty member with a strong track record as an educator sit in on a session or two and provide a constructive critique? What plan could the junior faculty member develop to improve the quality of his or her teaching? By shifting the focus to internal factors over which learners have control, they are empowered to make improvements.
Mistakes and Failure
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 success. By contrast, labeling oneself a failure proves 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 (8). Perseverance, not genius, is the more characteristic trait of successful people. 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.”
Many medical students and radiology residents are accustomed to success, which sometimes leaves them at a loss when they are confronted by disappointment. In reflecting on their own level of perseverance, learners must appreciate the difference between the mule and the fox. When the mule tries something and fails, he tries the exact same approach again, only harder. By contrast, when the fox makes a mistake, he too does not give up, but instead of simply repeating the same unsuccessful approach, he tries something different.
When Churchill said, “Never give in,” he did not mean that people should never learn or change, bullheadedly banging their heads against a wall until either the wall or their head gives way. He meant that, in attempting to achieve their most important goals, people should bring into play all the experience and ingenuity at their disposal, trying out new and different approaches until they find something that works.
In medical education, many of our evaluation rubrics tend to discourage this innovative attitude. Most written tests, for example, tend to encourage conformity, the view that there is only one right answer and every other response is incorrect. Memorization and recall are what we reward. Not only does this tend to discourage the skepticism and creativity upon which future innovation in our field will depend, it can also undermine learners’ future abilities to respond effectively to setbacks. Perhaps not coincidentally, as a student, Churchill graduated at the bottom of his class, in part because he felt that he was being forced into a mold that did not fit him. This world-class writer, artist, and statesman, who won the Nobel Prize for literature and became one of the greatest political leaders of the 20th century, spent most of his youth on the verge of flunking out of school. While we would not want to encourage our medical students and residents to perform poorly on conventional measures of learning achievement, we should bear in mind the importance of encouraging learners to treat setbacks as opportunities and not as a sign that they do not have what it takes.
Caution and Risk Taking
To say that successful people tend to take risks, or that unsuccessful people tend to shy away from them, captures only part of the truth. There are two ways to win a competition. One is by choosing opponents whom one can easily defeat. In choosing this path, people indicate that winning is more important to them than learning to perform at their best (9). By contrast, other people seek to expand and strengthen their capabilities. They are less interested in merely winning than in raising their level of performance. In some cases, such people also have an interest in the performance level of others and seek to help them do their best as well. Comfort and fear of disappointment or defeat can become enemies of human achievement if they undermine one’s willingness to take risks and push oneself and others to higher levels of performance.
What risks could learners such as radiology residents possibly take? The following is a short list: Find a problem in radiology’s knowledge base and develop a research project to study it. Develop a lecture or interactive instructional module to teach a fundamental facet of radiology to medical students. Take an evening course in art history, philosophy, or leadership. Write a two-page critique of the radiology residency program. Interview each of the residents or faculty members in the program and compose one-paragraph biographic sketches for distribution throughout the department. Spend a month helping to deliver health care in a foreign country. While such experiences would likely prove worthwhile in their own right, they would also help residents begin to think in broader terms about their mission as learners and foster the ability to look at radiology in new ways.
Individual and Group Learning
Some of the best contexts for learning defy our conventional practices and expectations. For example, our testing and evaluation rubrics focus at the level of individual achievement, implicitly encouraging an individualistic approach to learning. In fact, however, learning in groups sometimes proves a more effective approach. Consider, for example, the study groups that many residents create to prepare for the board examinations. What can we learn from such learner-generated learning environments?
1. The rosters of such groups are flexible rather than fixed, allowing members to come and go as they see fit and develop their own ad hoc rules for learning (10).
2. Because such groups are small, they are better able to tailor learning tasks to the knowledge level of each of the members, creating a more efficient learning environment.
3. The groups turn the typically individualistic focus of medical education on its head and assign learning tasks at the group level, thereby encouraging cooperation and mutual edification.
4. The groups provide truly substantive evaluations of what each member does and does not know, and they do so on a regular basis, rather than merely issuing a “report card” at the end of a few months or a year.
5. The goal of the groups is not to sort and rank learners but to provide every member of the group an opportunity to learn.
6. When the groups identify and correct mistakes, they do so in order to improve each member’s understanding and not to determine who is the best.
7. The groups ensure that learners are active participants who assume responsibility for their own learning
and that of other members as well.
In order to achieve something, it is vitally important to clearly 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, the directors of 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 nonradiologic and even nonmedical elements in success and failure, radiology education programs can better prepare their learners to realize their full potential
0 comments:
Post a Comment