• Rebecca McAlister, MD, Professor, Department of Obstetrics and Gynecology, Associate Dean, Graduate Medical Education, Washington University School of Medicine


Upon completion of this session, participants will be able to:

  • Explain the concepts of Grit and Growth vs. Fixed Mindset.
  • Assess learning styles for Grit and Mindset.
  • Apply these concepts to the health care education environment.
  • Apply these concepts to address clinical examples of struggling learners/faculty.
  • Utilize these concepts to build a supportive clinical educational environment.

So good morning everybody welcome to today's teach education grand round session thank you so much for joining us uh early this morning we are all in for a treat this morning um dr mcallister did her first iteration of this presentation yesterday and it was just lovely and i learned a lot and i hope that you all will too so non-cognitive traits such as the skills associated with motivation attitude and temperament rather than intellect are increasingly recognized as important skills to identify and develop in medical professional learners so a growing profession uh i'm sorry a perception that many learners are ill-equipped to handle the rigors of health professions education and training is forcing programs to change their approach of how to successfully advance their students through the curriculum and prepare them for the real world uh consequently many educators may struggle to find an appropriate balance between being supportive while also challenging students to take responsibility for their own learning so today to help us navigate through these muddy waters i am so pleased to introduce dr rebecca mcallister dr mcallister is currently professor in the department of obstetrics and gynecology and associate dean for graduate medical education at washington university school of medicine she obtained her bachelor of science degree from the university of kentucky her md from the university of kentucky college of medicine and she completed her residency in ob gyn with loyola university-affiliated hospitals she has worked in private practice for an hmo and has spent most of her career in academics holding multiple education leadership roles including serving as program director dio and associate dean for gme so pretty much the full spectrum so today dr mcallister will share her experience and wisdom through her discussion entitled growing a gritty educational culture developing a growth mindset to build passion and perseverance in our learners so one final note before we get started be sure to let us know you attended this session so there are two main ways you can do this you can complete the form for g cme and or faculty development related to teaching the link to which sandy has and will again post in this chat and at the very least please make sure your zoom name reflects who you are so if your name is currently your phone number your spouse's name uh generic iphone or anything else that will not identify you you can easily change this in the participant list just click on participant um and then click on the three dots in selecting rename and just name yourself to whatever you'd like but hopefully something discernible for us so without further ado i'm happy to turn things over to dr rebecca mcallister well good morning where you are it's early but for me it's about an hour earlier so it's a bit dark um but i'm happy to be here i'm just sad it couldn't be in person that was really my plan is some of my best friends in the world are there career with dr weiss and dr lehrman so dr weiss is on the phone call this morning and hopefully we'll get a chance to just say hello to each other after we're finished but but it's fun to talk about this topic this is something that i've enjoyed speaking about for the last few years and hopefully bring some new thoughts to it as often people have heard about grid or birth mindset but there's a lot going on in this field and so we'll try to touch on that as we go through this one note is we're going to do actually the screens the grit and the growth screens and so if you want to participate you might want to get a piece of paper and something to write with just to make it a little easier to keep your scores uh handy to you but it's up to you so we'll deal with that in just a second so i have no conflicts of interest um and our educational objectives are to discuss the concepts of grit and growth versus fixed mindset uh to assess your learning styles for grid and mindset um and to apply those in the healthcare educational environment which is what we all work with every day every day and also to apply these concepts to maybe some examples of the kinds of struggling learners and faculty that you might run into and to just give you some extra tools to help deal with those people so that they're better able to address the problems that face them and then just overall discuss how these concepts can help you to build that supportive clinical educational environment that supports us all so we are going to take a couple of minutes just to think about this as i said you may have heard of grit you may have heard of growth mindset actually if you have kids in school you probably have heard of this because this is very commonly discussed in the elementary and secondary education to the point it's just about indigenous to that and many people that's their first exposure to it but you may not have taken the actual grit and growth spores so i believe and i can't actually see the the um chat so we had talked last night about putting a link to this in the chat if you wanted to see it more closely because it may be a little bit small for you guys um but this is the grid scale that had been uh developed by angela duckworth in her book and it's from her book grit the power of passion and perseverance which is the source for this talk today um and it basically is just 10 questions 10 statements that you read and then you decide how much is this like me and then you give yourself a score so you need to pay attention to the scoring because it does change uh from negative to positive over the 10 items so make sure that you give yourself appropriate scores and you can do the percentiles if you want to but you can figure out as we're going through this where you are going to fall one word of caution there is no wrong score ultimately your your day-to-day score will change certainly your score over time will change so this is just to give you a global idea of where you might fall so i'm going to give you a little music in the background to help me be honest and give you three minutes to be able to work through this i'm going to turn it on now and then we'll switch to the mindset and sandy has posted the scale in the chat so you can go ahead and click on it if you'd like to see it a little bit bigger [Music] [Music] so [Music] almost finished [Music] okay i'm going to turn that one off just so we can save a little bit of time at the end and again don't overthink these because it really is just your impression this morning not necessarily something you're committing to for life so that was the grid scale again you can look at the scoring later and figure out what percentile you would be in but this is pretty fluid so i wouldn't again fixate too much on that we're going to switch to the growth scale now which is uh developed by carol dweck and this is again the basis for her research and something that we'll talk about extensively as we go through the rest of the talk uh but this has only eight statements of the little more detailed they have a longer likert scale but it's the same concept so it really comes down to read the statement and then agree or disagree with whether you not whether or not it represents the way you feel this morning uh and this one that doesn't flip so it really is one is disagree and sixes agree a lot so again i'm going to turn on the music and we'll give it as close as i can get you to three minutes but it shouldn't take you that long don't don't overthink this stuff it's just to give you a feel for what the basis for our research that we're going to talk about has been [Music] [Music] this is a reminder this scale is below the grit scale on the attachment that sandy put in the [Music] chat [Music] and again don't worry too much about the scoring it's a little bit more complicated for this because of the reverse scoring we'll figure out where you're you're you're falling as we have the discussion so i wouldn't worry about it for now [Music] we will also have these scales posted on our website so that later if you want to retake it or if you want to share with some colleagues you can do that also i'm going to cut it off just because i want to save some time at the end so we can have some discussion but again don't overthink this this is just for you to have a feel for what what the questions were that drove all of the research behind these two concepts so we're going to move on and this is actually a very short clip i'm actually going to make it a little bit short this morning um of dr angela duckworth's ted talk in which she discusses her concept of grit this came out about 2017. this is actually one of the most commonly viewed ted talks she's an excellent speaker and it's actually in your bibliography at the end so if you want to go in and see the whole thing you're welcome to do that it's probably worthwhile because it's a nice some uh summary of the concept of grit and what she's trying to get across because she is the face of grit so i'm just going to run a couple sec a couple minutes of this in education the one thing we know how to measure best is iq but what if doing well in school and in life depends on much more than your ability to learn quickly and easily so i left the classroom and i went to graduate school to become a psychologist i started studying kids and adults in all kinds of super challenging settings and in every study my question was who is successful here and why my research team and i went to west point military academy we tried to predict which cadets would stay in military training and which would drop out we went to the national spelling bee and tried to predict which children would advance farthest in competition we studied rookie teachers working in really tough neighborhoods asking which teachers are still going to be here in teaching by the end of the school year and of those who will be the most effective at improving learning outcomes for their students we partnered with private companies asking which of these sales people is going to keep their jobs who's going to earn the most money in all those very different contexts one characteristic emerged as a significant predictor of success and it wasn't social intelligence it wasn't good looks physical health and it wasn't iq it was grit grit is passion and perseverance for very long-term goals brick is having stamina brit is sticking with your future day in day out not just for the week not just for the month but for years and working really hard to make that future a reality brit is living life like it's a marathon not a sprint a few years ago so we're gonna stop her there again this is a much longer video and something that's fun to listen to if you'd like to but you know you you hear this kind of discussion and you see multiple examples you hear multiple examples where the high performers the people who really achieve the most seem to be scaling or scoring high on the sprit scale and everybody's like oh this is so exciting you know this is something that she hadn't she's the first to have described and the question really is where does this visit fit in she herself will tell you as you listen to the video that this is a very new concept and even she can't tell you as much about it as we would like to know because it's still very early in the research issue but it has caught on it certainly has a lot of followers and that's really our first question today is what about grit can we can we take from this and and how can we um enhance that or encourage that in ourselves and in our learners and so her definition of grid is that you have passion for whatever the goal may be and that you're able to persevere so that together that the combination of passion with perseverance is what she conceptualized as grit so in her book she discusses what can you do to build grit and again she's theorizing they don't have data to suggest that this is actually going to always pan out but the the concept really is if you don't have the it's like the pearl if you don't have that little nidas of something that that is in the back of your mind it keeps you thinking about it day and night so no grit then you don't develop the pearl or the success at the end of the day so what can the individual do to try to enhance the success and the perseverance for their goal one is to develop an interest and so you really need a guiding fashion to be able to decide how well i focus myself in the early years maybe even up into adolescence and sometimes into adulthood there you're still in a in a adventure finding mode and you don't have to be as focused as someone like tiger woods was and choose your your life's passion when you're four years old but certainly you need to sort of hone things down and develop a specific concept that you're working toward and then the most important thing is to practice that so it's not just practice in an arena where you feel comfortable you need to practice at the outer limits of your capabilities and so at the outer edge where you're actually having to work harder to be able to do something that kind of practice is where you can get the 10 000 hours to make you an expert and that kind of practice would be necessary in order to be successful in achieving that long-term goal a really important concept that she believes makes this different from other other similar concepts is the the idea that you have a purpose in achieving this goal so it's bigger than this is fun it's bigger than wouldn't it be neat it really is it's something that's going to make you a better person to make the world a better place to live in and achieving that is worth all this work and time that you're putting into it and most importantly is hope so it needs to be a realistic goal you can't make yourself taller to be a basketball star you may not be able to make yourself a better pianist no matter how hard you practice but you have to have hope whatever you set as your goal that you can actually achieve this and that's what we as educators can help with nonetheless it needs to be a realistic goal and one that you're able to see progress with over time so that would be what the individual could do and this is her concept of how you might be thinking about the goals that the individual could set over the course of their life and so if you know the higher level goal the top level may be the place that you want to wind up at the end of the day or the end of your career wherever you believe that that goal could happen but you don't get there directly you have to work through your these lower level goals and mid-level goals that will build on each other and get you to that higher goal so this is all lovely until of course the inevitable happens and something blocks you you're not able to get into the school that you think you need to get into you don't make the cut on the team you you don't win the spelling bee so what do you do if that happens how do you reroute yourself or do you just rethink all of your goals and that's really where her concept comes in to say don't let this defeat you don't let the defeat of or the failure to achieve these low-level goals derail the concept that you've you've developed that you wanted to achieve and so being able to reroute those goals and come up with a different way to get to the higher level goal or using it thoughtfully to say was that goal really appropriate did i set my my sights on something that's not achievable is that really what i want that flexibility is an important piece to grid and something that hopefully will keep you out of being in a dead end where you find yourself continuing to to push against the wall that doesn't move and so you really need to be able to be flexible and be sure that the grid is appropriate as einstein said it's not that he's smarter he just stayed with problems longer we might be able to debate that but the ability to stay with that problem in a longer period of time does make a difference and so as educators we want to be able to help support people and help them achieve their goals so this is really building grit from the outside in whether you're an educator and in her book she uses parenting as an example that's very appropriate i think many of you out there probably have done have had the same kind of discussions uh with your children along the way or if you haven't you will so building that supportive environment is important and one of the key concepts for from her book and also from dr dweck's book on mindset is it's important as we're supporting our learners or as our children that you emphasize their effort to achieve whatever it is they're working hard not their talent or their innate ability to do something you know or what they were born with and so that may be a little difficult to understand how that feels but at least from their perspective this is an important message that i see what you're doing and i see how hard you're working at it and i'm proud of you for that i believe you can be successful with that not this was just the way you were born and it's just need for you so we'll talk more about that in a second but the ultimate uh the other two will get you in just a minute so that praising the effort and not the talent may look different so your spontaneous thought may be oh you must be smart of these problems if somebody's some some child or some kid has been able to uh be successful in answering some math problems but you could instead say wow you must have worked hard at these problems so again you see the difference emphasizing the effort but so if the learner completes the task too easily you might say well you know let's pick something harder so that was pretty easy for you that's great but really we want to challenge you so let's work with on something harder so again you want to emphasize the struggle the fact that they were able to see the task through particularly and and i i believe in medical uh health professional fields you want to be certain that you recognize that they're able to act on criticism this is something we all struggle with and that they take the initiative to go beyond what you have said there as their short-term goal perhaps and that they're working even harder to be able to achieve their long-term goals so you see the difference but that that support from the mentor or the trusted teacher really makes a difference uh certainly in their studies and and i believe probably a take-home message from all of this so the clear the other piece to this and growing uh grit from the outside in is clear expectations uh and giving them the message that we expect them to be able to achieve again something that's easy to say but we don't do it as as well as we probably should so what are our expectations for our learners in this moment today for our short-term goals and what do we really think they're going to be able to do so you may have matched them into your program and you believe that they're going to be a successful person in whatever field you're training them in or you may be you know helping them to become a spelling bee champion or a swimmer but if you believe that they do have the ability if they work hard enough to be able to achieve that you need to communicate that to them and to give them the clear expectations of what you believe it takes to do that that goal and how well you believe they're doing it what suggestions you have for them to do better so that honest coaching and being able to tell them the truth and give them those high standards to meet is is on this graph this was one for parenting where they point the difference between undemanding versus demanding and supportive and unsupportive so the neglectful parent is not both unsupportive and undemanding so you just sort of hang around with the kid versus being a permissive parent which i have to admit there were times i was accused of that where i was very supportive but not particularly demanding so very forgiving and more likely to comfort them and say things like it's okay you'll do better on something else something that we also do in medical education and we need to think about that before you say things like that even though your intent is to make somebody feel better versus the authoritarian parent who's very demanding but not particularly supportive you have to pull yourself up by the bootstraps and of course we all want to be in that wise parenting quadrant where you're not just demanding but you're supportive and you give them those expectations and you let them know that you know that they can make it so again think about where you fall on this both as an educator and particularly as a parent and our striving is to get to that wise parenting quadrant so that honest coaching and feedback is really important i know everybody has been through courses and and had many discussions about giving feedback and being the coach and that coaching model is very pertinent but making sure that you're doing it consistently and again phrasing your support by praising the effort and not the talent is a shift that you might think about in order to be able to give this messaging to your learners so scaffolding is something that has been discussed in again secondary and primary education but that is something that we do every day in medical education so the idea is the expert the attending would be the one who is there with the learner the resident of the medical student uh to be able to show them what to do what theirs their um goals are with this particular patient encounter but you're helping helping them to learn to do something that they've never done before doing it in the safe way you're there to protect the patient and to teach the students what they need to do to be both able to work at the outer margins of their ability and that that really is the essence of good medical teaching and good teaching in general so this is a picture of dr carol dweck who was a mentor for dr uh duckworth and and her work is really the the underpinning for dr duckworth's work which she freely acknowledges and actually they've actually had a couple of things that they've done together but dr dweck's worth is much more established in medical in uh secondary and primary education to the point that you it's difficult to get through elementary school these days without somebody talking about uh the mindset and whether you're in a growth mindset or a fixed mindset but in her own words she says you know that challenges are exciting rather than threatening uh and that if i'm revealing my weaknesses it's a chance to grow so that's really the point is you can't learn unless you fail if you're always right then you haven't really had a challenge to that and so that's really her point in making sure that we as educators recognize when when failure occurs that we need to support this the student and actually her favorite phrase is you didn't fail you just haven't succeeded yet so uh dr duckworth actually includes this in one of her uh talks with hashtag women who work the gritty people have a growth mindset when bad things happen they don't give up so this this is uh a quick discussion of the the research that dr dweck did again uh this is frequently in elementary uh schools and this this work was done on fifth graders for reasons i don't understand fifth graders are frequently the subjects in some of these studies and it's been repeated multiple times i'm just going to run through it quickly because again i think it helps all of us to understand what was the the core research and then make our own decisions as to whether it's applicable today in the world that we have to deal with so again working with fifth graders they took uh children and gave them math problems that they knew were too difficult for them so they knew that no none of these kids would really be able to do these easily divided them into three groups so the kids took the math test and then they they had a score but the investigators divided the kids into three groups one group was told that they had a high score but nothing else so they weren't given any feedback other than that so that was the control group the second group was the group that was told you had a really high score you must be smart at these problems so clearly praising their intelligence and saying that must be the reason that you've got the high score and then the third group which is really the group that we're most interested in we said you got a really high score you must have worked hard on these problems so these three groups will be what we follow through one was just you you know your grade was high the second one was you must be smart because you got a high grade and the third one was you must have worked hard at these because you got a high grade so what happens to these kids they were offered the chance to uh do some more problems having gotten this test result back and they were offered either to do easier problems or harder problems so when you look at these three groups you see that the middle group the groups whose intelligence were praised were more likely to choose the easy problem so they you know that the concept of doctor would explain this with is that they believe that they were smart and they don't want to challenge that self belief or the belief that the teacher has if they're smart so if i do easier problems i'll be able to do better i'll choose the easy problems as compared to the kids who were in the effort group whose effort was praised and they wanted the challenge and so they were less likely to choose the easy problems and of course the kids who got no feedback were about the same as the kids who were praised so again they were given now a more difficult set of problems and told that they did much worse so everybody got x grade but they were all told that they did much worse on these more difficult problems how did they do differently interestingly when they were offered the chance to they were told that they didn't do well but when they were offered the chance to take them home and work on them more try to figure them out more since they didn't do well on the test in class the kids whose intelligence was praised were less likely to be willing to take them home the kids whose effort was praised were the most likely to take it home because they saw they believed that they saw a challenge with this that they wanted to continue to work on so sort of what we want in our learners uh then they were given another set of problems that was about as difficult as the first set so that about the same level that they should probably by now be able to work on so kids who had only been told what their scores were were this bottom row and they were about the same they did a little bit better since they worked on these kinds of problems before the kids whose talent had been praised whose intelligence had been praised actually did worse and the kids whose effort had been praised did much better so interesting that their outcomes would change with no more than just the intervention that we talked about at the beginning the part that really bothers me is what they did with this information and so the investigators offered them a chance to write a theoretical letter to other kids in another school someplace that would be taking this quiz taking this these math questions and explain to them what it's like and how they did on it themselves and so in their letter to these kids the question is did they inflate their own scores so the kids whose talent had been praised were much more likely to inflate their own scores particularly compared to the control group and the kids whose effort had been praised so that's kind of scary that they actually lied in order to cover the fact that they didn't do well now is this really translatable is as simple as simple something as simple as just saying you did well because you're smart versus you did well because you worked hard really going to change their life and if it is you know can we change that that perception that's really what the discussion is going to be for the rest of our talk so in the just in the medical literature concept really has been that people who have a growth mindset can accept negative feedback and are good at remediation because they want to get better they believe they can improve they don't view failure as at the end of it they view failure as opportunity to grow where a fixed mindset is described as often being defensive because they're trying to protect that self-esteem they don't believe that they can improve they believe they are where they are and it's just not going to change but frequently they tend to compare themselves to others who didn't do as well to make themselves feel better about themselves so that's kind of a unpleasant attitude that many people who have this fixed mindset or felt to take but teaching is a very deliberate action so what can the teacher do to change that mindset and to help people move toward the growth mindset which is clearly where we want our learners to be so these were some studies from dr dweck's group that looked at what the teachers perceptions could do for or to the learners so if the teacher was was of a growth mindset that encouraged risk and effort than it and that felt that their learners could learn from their mistakes the kids were much more likely to do well the problem is when the teacher had uh sort of mixed messages and so they may have been told yes we're in a growth mindset mode but they really didn't believe it and the sort of subliminal message or the hidden curriculum was no it's really okay so even if you don't meet my expectations you'll be okay and that feeling that you are being comforted because you failed can actually sort of subvert the whole concept that your growth mindset is where you should be and also if they praise talent instead of praising uh effort that can also support things too so those kids who got these mixed messages some were actually demotivated and had lower student self-expectations than the kids who had been in the growth uh mindset teachers classes so that's not the way we want our kids to to react um this was a very simple study that was done again i think this was in high school students but they were mainly working with kids who are not performing well and and the core to this is to to give them the information they need to understand that your brain is is really functionally like a muscle and the more you work it the more you can grow neurons and have new pathways and and establish those pathways well which is a different way than it was described when i was in medical school where you were told you had a set of neurons that just decayed over time so this is much more heartening to think that you actually can grow more neurons we know this is true so this actually encourages risk-taking and uh learning from mistakes and so that that message was given to kids in a just online basic education course that these kids took and they actually did see that the scores for these high school kids improved having had this this very minimal intervention online so pretty encouraging just to see that that change could happen with that so what about medical education it is percolating but certainly has gotten into college level and in medical education it's really more theoretical a little bit of actual um studies being done but for the most part it's people who are who are commenting on this is something we should look at this is something we should do so this was an author who felt very strongly that this might help students and ultimately physicians be more willing to deal with medical error something that we all struggle with and so they felt that you know teaching kids in as in a setting that was really more simulation rather than actual patient care would allow them to uh make the errors that they could develop their diagnostic reasoning without having to worry about whether patients were harmed and in reinforcing this learning as a result of mistakes should start in medical school and no one just really disagrees with that but you know the question is how much difference will it make um and then ultimately there are some situations that are already in our system that can reinforce this as they get into the clinical years so schwartz rounds are a national effort where they have uh inter-professional discussions about some poor outcome that occurred in that in that institution and they discussed how could this have gone differently in a very non-threatening way in a very uh non-blame way that could hold hope excuse me ultimately hopefully uh decrease the chance it would happen in another patient grand rounds and eminem uh have evolved toward this and that's really most people's goals and getting away from the blame and shame game that was much more common in years gone by but again thinking about there was a problem how can we prevent that problem not whose fault was this problem and what mistakes were made so mistakes do have to be called out but you want to do it in a way that's looking for ways to prevent that in the future and minimizing the individual's fault as it were because they need to feel like they can move beyond it uh this was a one of the few studies that's been done so this was a at a pediatric hospital where they gave the mindset screen that you took earlier that uh so they gave it to the residence fellows and attendings about half of them responded and they found that in this group of pediatricians there was no dominant mindset so sort of the normal curve that you might expect and also they found because they asked these people if they were willing to report medical errors that mindset whatever mindset that they scored on their on their screen did not really correlate with the reporting of medical errors so sort of going against the hopeful message that the previous author had but we if you think about it we really are beginning to understand that who reports medical errors and how they're reported is really a very complicated problem and something that probably something is as straightforward as mindset and whether that makes you more or less prone to it is really too too simple and doesn't really explain the whole thing but there's some other pieces of this that we'll talk about more that may draw on it so one of the uh papers i particularly like is this paper by do little and you see the title at the bottom sort of intriguing so failure and residency education lessons learned from harry potter oprah winfrey and the marigold hotel which occurred which was published in the journal of graduate medical education in 2019. so the reason they they have that title is because they use the examples uh in this in this title to show that you can't predict success by initial failure so the author for harry potter actually was turned down by 12 publishing houses before she was able to finally get her first book published oprah winfrey was fired from her first job in television and told she wasn't fit to be a television uh host and then of course uh for those of you who are familiar with the the indie movie um the marigold hotel this was the story of some british expatriates who felt themselves were failures moved to india where it was less expensive and the kid who was the maitre d at the hotel had a very positive attitude and so some of these quotes are from him but the the problem that they're trying to get at is that in medicine we really don't like to acknowledge our faults because you know we have a very high responsibility we're concerned that if we make a mistake people will be hurt harmed and so we don't want to forgive ourselves for our faults and unfortunately we still have faults so we have a tendency to cover them up and ignore them you know the phrase is we bury our our mistakes uh rather than acknowledge them but the reality is that the only real failure is the failure detribe which is a quote from the author of the paper but the the character in the marigold hotel states that if everything will be all right at the end if it's not all right it's not the end so as long as you're going to keep trying you can make progress and you can work toward the goal you just need to be flexible and to keep your positive attitude so that you'll be able to continue to work toward that uh then interesting paper from actually now a very long time ago 1991 by a guy named albert wu now this was long before the the present interest in patient safety and reporting and all sorts of things that have become more commonplace now but his his concept was do house officers learn from their mistakes this has not been repeated to my knowledge in this paper um in university of washington internal medicine residents they were asked the question have you had a serious mistake and will you describe it so 45 of those residents responded by saying yes i have made a serious mistake and you see the breakdown so sort of all across the line but the the interesting part is what they did with it so 90 of these these residents reported as a serious outcome 31 resulted in death and these residents believed that they were directly responsible for these outcomes of those people who said that they had a mistake 54 discussed it with attending so that's somewhat encouraging uh 24 discussed it with family now again this was before there was a lot of discussion about having these these uh revelations with family so i'm not really sure we want our house to have to go do this alone they didn't really ask if they did it with longer faculty but the sort of take home message is if the residents were willing to accept their responsibility and that they had they saw a way having discussed it with their attendings to avoid that in the future they were much more likely to learn from those mistakes for those residents who blamed anything but themselves the overload of their work that the the institution was too judgmental and they did not discuss it with their attendings or with their trusted advisors they were less likely to learn and more commonly would just ignore it and try to avoid those patients in the future so they really didn't get the benefit from it but even if those residents who did discuss it whose cases did come to conference almost half of those residents said the tough issues were not discussed the faculty were not willing to really get into what was bothering these residents about what happened and and what they believe their personal culpability was so that comforting that it's okay i'm the captain of the ship really may not get at what these house staff need and something we need to take into consideration when we're running grand rounds or whatever the discussion may be so that it's important to acknowledge that yes they were the person at the bedside that night and this is what your role in this was but there are ways that the whole system can support you to minimize the chance that that would excuse me that would happen again so there's another very interesting article called risky business and what this is getting to is not the tom cruise movie but it's discussing how difficult and how scary it is to be a learner in the medical education system these days because so often your personal worth is on the line or at least you believe your personal worth is on the line and so that gets to the concept of psychological safety so do you as an individual believe it's okay for you to admit that you don't know that you are guessing that you don't know the right answer to the question that's being asked that you do or don't know the the details of your patient so i think most of our our house staff and our students realize that you really shouldn't overstate what you know about clinical details but frequently they're not sharing with us and possibly not even with themselves um the idea that i really don't know what i'm doing and i have questions but i'm afraid to ask because i don't want to show myself as being inadequate in this study the the house staff who answered this the screening tool for psychological safety they found that those house staff were more likely to respond if the faculty and the colleagues around them were willing to deal with mistakes openly and welcomingly so that that may mitigate or exacerbate the risks of learning and this building of psychological safety is a common theme that's becoming more and more popular more and more recognized as something that probably is the distillation of that growth mindset and grit is being able to deal with it because you're comfortable discussing where your your holes in your knowledge are or where your errors are in your reasoning so again we said at the beginning not to be too focused on what your scores were for either the grid of the mindset because it changes it changes not just over time but it changes in minute to minute really in the situation that you find yourself in so this was a very recent article by a guy named huffman in medical education where they were talking about what the resident's perception of the feedback they were receiving was and so if the resident's perception was that the person who was talking with them was going to grade them so there were consequences to what this interaction that we were having um would would generate so i will be found to be wanting versus successful that resident was much more likely to approach that discussion with a fixed mindset i can't get better and very likely probably didn't reveal as much as they could have because they didn't see that it was going to help them and they wanted to look as as good as they possibly could to get the highest grade we're all pre-med at heart versus if there was trust in the supervisor that this was really just intended to help you get better then they were more likely to approach that interaction with a growth mindset so you see it's a very fluid concept and something that it isn't one of the other in any one individual even at any one point in time there's a lot that we can do in our educational environment to support it and hopefully push people more toward the growth mindset so they're willing to hear the feedback and to to act on it in a positive way so what else is there about in the grid in the medical literature so a couple of uh articles have come out and these were actually early in the in the time frame so as i said the grit book came out in 2017 these articles were in the 2000 teens too uh dr sally's who had been at washu and now has moved on to other places uh had found a correlation between surgical resident well-being with some of the well-being scores that you're all familiar with uh and positive grid scales or hybrid scales and then dr walker noted that the residents who had high grit scales were more likely to successfully complete surgical training so two outcomes that we obviously want and it makes it very enticing to say well i must want pretty residents so critic in the literature has also been associated negatively by low grit scores increasing the chance for attrition from surgical residency and increasing the chance for burnout in surgical residence there also sadly is an increased risk of suicidal ideation with people with low grit scores you know in a sort of dark note though if you have hybrid scores and you have suicidal ideation you're more likely to successfully complete suicide so some some very sobering thoughts related to grit with that although hardly cause and effect so again the early enthusiasm for grit kind of got the the card ahead of the horse and there was some discussions about should we just find gritty people and that would improve our outcomes and we would not waste time with people who weren't going to respond so this first article that came out uh in the journal of graduate medical education was by two non-physicians who just blankly recommended that both in for medical school and for residency and fellowship that we should screen for grid in their applications uh and that the review for resume for evidence was important on the problem of course is that this has never been validated and certainly dr beckwith wouldn't recommend it and probably not a good use for the grid scale per se another early adapter a doctor was a group of orthopedic surgeons who felt that they they believed grit was important for orthopedic training and this dr kelly screened all of his orthopedic residents and medical student applicants with the grit scales and found by golly they all had high grit scores so he recommended that they um look for non-cognitive variables in the selection process which is actually a good thing to recommend although they were depending heavily on the grit scores but we'll talk a bit about other things that you might look at rather than screening all of your applicants with the grid scores so really sadly is a chicken and egg there's no causation that's ever been proven with any of this and we don't know if people who are more likely to succeed just happen to answer those questions uh positively and dr duckworth's score versus know we can really make a difference and we can change their grit scores to in a way that would increase their chances for success other than building a supportive environment so focusing too much on grit probably isn't appropriate she has done dr duckworth has done more work she actually has a background in that in the business and so this was an article in the harvard business review where she and another investigator discussed the concept of organizational grid which is important because that's really what we are able to impact more than anything else and so when you're reviewing your applicant's track record you want to look for multi-year commitments you know the fact that that they've been able to stay with something over time and been successful in that and so if you wanted to to program a bit you can ask them if they've bounced back from failure in the past and how they demonstrated flexibility either with a real life example from their past or making something up either way would get at the same concept but you also want to get a feel for whether they're driven by a purpose that's bigger than themselves possibly one that resonates with the organization so being able to look at a resume and try to define that is helpful but more importantly you want to build that organization yourself so that that's the belief of everybody who's in your organization rather than um stating that we want these people and then having a hidden curriculum that defeats it so we're going to quickly go through a couple of examples that could could illustrate how you might look at these concepts as you're dealing with some people who might be struggling in your environment normally i like to do these as breakout sessions but clearly that's not going to work for this morning so we'll just set the thus the examples up and i'll give you my thoughts on what i think could be happening but again these are these are not real people but it should they be real people it's really probably more than just a straightforward answer but something to consider as we're going through it so we'll give you a second to think about it but then i'll chime in with my thoughts so the first is the helpless medical student marie is a third year student on your clerkship she's done well in her pre-clinical years but now has reported as not participating in participating on teams she's pleasant but quiet does not volunteer information on her patients when she's asked she can usually answer questions about disease entities but she doesn't really apply it well to clinical problems she's hesitant to venture a diagnosis or suggest a plan and so the residents are going to have questioning her fund of knowledge so i think we've all run into these quiet kids who who are smart we know they're smart but they just can't seem to make that leap to apply that to to the clinical situation is that because they're afraid or because they really don't see it i think this would be an example of somebody who has potentially at least in this situation the fixed mindset doesn't want to risk not being right and so she doesn't say what she's thinking and you are therefore not able to help her redirect her her uh diagnostic reasoning and and come up with the right answer so if you were her either attending or her counselor you might take her privately aside and talk about the fact that it's important for her to voice her thoughts so that she can learn from those and that it's a supportive environment that wouldn't wouldn't risk her loss of face if she was able to say what it is that's in her head so students are a real delicate group and something that we want to be sure that we've given them support but then they get up to the residency level and here we have the overwhelmed resident so nick is an intern in obgyn he was high on the match list good grades strong school and he had good evaluations in his first relatively easy outpatient gyn rotation however in his second rotation on gyn oncology which is more challenging he actually was not able to efficiently gather the needed information around sometimes forgot uh important details so his attendings who were pretty blunt said he just didn't know his patience and he was clueless in the or so that was devastating to him but the third rotation on what labor and delivery days it was also challenging and he is clearly overwhelmed there's a lot going on and he just can't figure it out senior residents find him spending too much time on small tasks neglecting emergent needs so he comes to you either as the advisor is the program director he's unwilling to ask for help but he tells you that he's considering switching to family medicine so sadly this does happen sometimes in first year ob people but the question in this scenario is what could have set this kid up why would he be struggling now and see family medicine as his way out so i'll just jump in and give you my thoughts on it you know from the standpoint of you know where is his mind i think he probably is in a fixed mindset for this particular conundrum that he's gotten himself into and feels like he can't be successful even though he had been successful prior to coming to this residency and in his mind the answer is not how do i do better in the residency but the answer is let me just jump to a different solution so that that combination of a fixed mindset and lack of commitment to ob is that really lack of grit versus just somebody who's afraid and is looking for a way to get out of what he views as an untenable situation i think those are important discussions to have and particularly the discussion is is ob really the right place for you something that you want to focus on rather than making that assumption as you're having those conversations and then lastly we're going to get to the faculty number because again we don't get better at this we just kind of move along with whatever the trajectory is so this is a sub-specialty attendant who joined faculty two years ago as an associate professor he brings new clinical expertise and we were happy to get him but he makes many references to what happens we're done at his old school he's not willing to allow house staff to develop plans rather than his and he often clashes with chief residents because he says they they just can't run their teams he gets back poor teaching evaluation it's not a big surprise uh and he says well what do you expect from these weak residents when somebody tries to hold them to high standards so this person is dealing with what many of us deal with when we move institutions that they're feeling threatened they're feeling that their self-worth is on the line and their unwillingness to recognize any benefit from the new version uh is limiting their ability to interact with students and with house staff and so whoever gets the fun job of talking with them really can intervene and help this person turn it around so they don't go through the rest of their career being information that nobody wants to work with and encouraging them to to relax a bit and be welcomed in this institution and share their expertise but also to learn from the other people around them so that fixed mindset may be holding him back at this point but all this is interesting but is it really enough to get us where we want to go there's been some discussion about whether grit really is all that different from these other concepts that have been much more well researched in the literature and there's a real issue is whether this is just pop um psychology uh that dr duckworth happened to hit on she's a very persuasive speaker and it's really kind of gotten ahead of itself in some venues when people have tried to to replicate her findings actually this paper that is in your bibliography really wasn't able to do it as much as her data would suggest and so that really does make us question how can we utilize this information or is it really just to throw away actually dr duckworth worked with this german psychologist and i'm probably not pronouncing her name correctly gabriel edingen uh and they were looking at the concept of people with optimistic thinking positive thinking is that enough to get you there and dr ettingen would say that no it's not actually people who are only positive in their thinking but don't see the real obstacles are actually less likely to be successful and so being honest about those obstacles and working through a plan is much more likely to get you there so she and dr deckworth worked out this concept which is a little clunky clunky in the title mental contrasting implementation intentions which they they abbreviated as mci still not that catchy they ultimately came up with a different epineme a whoop to discuss recognizing obstacles and being able to work through them so whoop stands for the wish or the outcome that you want and that outcome is really something that you want to visualize what will you do better how will you be a better person because of this outcome and really think about those obstacles and what it feels like and how you really need to think about working around those obstacles and come up with a plan that would get you around those obstacles so that your action actually works out so going through that that process can change the result this was a study in anesthesia people who were i think they were residents who were on an icu rotation and the people who were taught loop were able to study more and that hopefully then there or have a higher fund of knowledge so they were able to average 4.3 hours of studying where the people who were just told let's set some goals is to study more and not given the background we're only able to achieve 1.5 hours of studying so some interesting outcomes and maybe something to look at and of course there's an app for it so those of you are interested in go to the app store and find it dr duckworth also did a lot with kids in elementary schools and there's something that her program she was at the is at the university of pennsylvania and they developed what they call the pen resiliency program to help kids learn uh optimism and be able to deal with their environment more proactively the problem was when they they got past the research group and tried to teach it to the teachers so that they could then sustain that in the classroom it didn't work quite as well so some questions about that there these were other examples that have utilized the same concept so there was a graduate student that worked with duckworth that worked on an australian football team and those people who uh did have the grid optimism and performance teaching were able to do better and interestingly in the us military they're utilizing this in something called the master resilience training which is an ongoing effort has reported improved outcomes in mental health and substance abuse but the final answers aren't in on this one yet the growth mindset actually is older and certainly something that's very deeply ingrained in secondary education but when they've tried to replicate it in this paper that's also in your bibliography it hasn't come out quite the same as what dr dweck's data would suggest it doesn't mean that there is a message in it it just means it's difficult to to replicate so how do i utilize all this what could we do that would make a difference and why is it all so complicated so for me at least the takeaway is what einstein would tell you is education is not learning facts it's training the mind to think and in the individual learner you want to certainly give them constructive and supportive feedback and help them support their own personal psychological safety to trust you that they can tell you the truth about where they are and what they need to do you might want to help them with goal setting and when they're having problems you can think about it from the standpoint of greater mindset and whether those things might enter uh face with them and be something that they could work on to be able to improve their outcomes in the organization we definitely want to build a safe organization psychologically safe organization where everybody discusses error as an opportunity to learn and the supportive learning environment then generates a lifelong learning environment so that's something that we all need to work hard on so this is the uh three ted talks that i would highly recommend that you get a chance to look at dr duckworth we we had a sample of dr dweck isn't quite the same level of speaker but her ted talk is actually quite good and this uh ex greater experiment is the fifth grade experiment for dweck's uh research that we talked about the beginning and these lists of articles that i've utilized in the books are in your um slide set and they have them on the website so you have a chance to go back and look at these if you're interested in getting more information on this the one that's highlighted in yellow is from dr amy edmondson who's the person who's really developed the concept of psychological safety in the workplace and it's really worth the read something that i think probably will be the take home message so my favorite teacher and philosopher is yoda and yoda tells us that the greatest teacher failure is and i think so long as we keep that sort of as our north star we and our learners will continue to to build on our failures and do the right thing and build a supportive learning environment so we do have a couple minutes left i've tried to leave some time for whatever thoughts or questions people might have um i'm happy to approach those now i couldn't i couldn't see the chat were there any things there that we need to do um there were just a couple of things so um dr schlupner mentioned a little bit early on that um sometimes easy let's see easy achievement on one issue project or problem just could be really focused talent and then immediately after that you got into some of how these concepts are very context dependent right so uh validating that point so i think that was a really important point for us to address and then a little bit later um uh dr slutner said or asked is um is grit really just a glass half full personality and you could look at it that way i think certainly the optimism is an important part actually dr duckworth's background was in the concept of tr i learned optimism so that's what her mentor taught her uh and she built on that but she believes in and dr edinger's and jen's work would support that that optimism on its own isn't enough you have to be honest with yourself and have your your mentors be honest with you so that you can work around whatever obstacles are there not give up so yes have stamina have great have perseverance um but have a realistic plan absolutely and recognize as you mentioned maybe ob gyn is not necessarily the field for you being honest with that conversation um but here are the things that you can achieve and if you are focused on them and you want to achieve them but also being honest and having that honest expectations and feedback um but as you mentioned and i remember you mentioning this uh more clearly yesterday i didn't hear it today i may have missed it but um really not trying to avoid saying well you're really not great at this but you're good at this instead so instead uh you know emphasizing the potential in all areas well that's the comforting thing and that's something i'm very guilty of i'm telling my kids would certainly tell me that that's something i did with them a lot because you don't like to see that that crest fallen face where they didn't do well but they need to hear that i mean you don't become a champion in any sport you don't become excellent as an expert in any field if you're not told the honest truth and so it's not that you're saying and you can't do it that's really the importance of saying and i believe that you can meet my high expectations so that should be the comfort not that oh don't worry about this you'll do better in something else absolutely this has been an excellent discussion and dr mcallister uh has expressed she's more than willing to stay after for additional questions she recognizes this talk um you know would get us from very close to the end of the hour but if you have questions or would like to continue the discussion please stay on for a few minutes um this has been an excellent discussion about um how to modify our own teaching to set up a growth mindset and potentially enhance grit for our learners um some some things stand out for me during each presentation and one in particular for this was really the importance of as faculty modeling um i don't think that can be overemphasized modeling that growth mindset if if you're uh talking the talk and and expressing the importance of growth mindset but then you don't see it in yourself and you don't demonstrate um the concept of lifelong learning and that you can always continue to grow and learn then this is gonna fall flat inevitably but um that was one of the most important things that came out for me um just some expressions in the chat about um what a great presentation this was um kelly henschel mentioned i have a learner who i think would greatly benefit from this talk yes this will be recorded also we have another session um this evening at five o'clock one final session so um all of the recordings or or the recording and all of the materials will be up on the teach website within a week's time usually a little bit less than that but we allow a week just for a buffer um but that will be on the teach website okay so also um emily nguyen says how does confidence relate to brit i would think one would need enough confidence to believe that they can overcome challenges but those with too much may think they have no growing left to do that's an excellent question and for those of you who need to to leave uh please go ahead and do so and those of you would like to stick around to continue the conversation please do so as well so i think you said confidence yeah so if you're confident if you're overly confident that's even more important that the person who's the supervisor sort of frame it as in this is where you are and you really are not where you think you are you need to be double checking with me you need to understand that there's a scaffold around you that's making you look good and if we take the scaffold away you may not look so good so i think those overly confident learners scare all of us more than anybody else but i think that may be a defense mechanism and something that you need to think about rather than just saying this kid you know can't even tell that they're not where they think they are as much as to say they're putting out what they believe you want to see which would be the confident face and actually there's good data to say that the more confident the resident appears the more likely they are that you'll let them do stuff so we feed into this fairly frequently and if the resident says sure i know what i'm doing and you go sure that's great i'll see you later then you just let that happen so you really need to keep your own guard up and be sure that you're accurately assessing what you know they could do not what you presume either from you know from the level of training that they are or their their stated confidence that they tell you i got this um because you know you're the one who is responsible and you do need to refrain for them well you know you're good at this but there needs to be you know some more work done on whatever the points are that you still think they have to develop absolutely i i see so many intertwining concepts educational concepts within this these these uh concepts as well so thinking about self-efficacy the feeling that you can persevere beyond in the most challenging situations even when you're faced with adversity or self-assessment where and we all know that none of us are great at assessing our own skills um right so those of us who well neither the other is you know when do you as the as the expert need to step in so i think you know some that's another hesitancy particularly junior attendings could be can be trapped by is to say i need to let them keep trying because if i take it away from them then they're not going to think i have confidence and clearly there's a line that you have to to recognize where it is in the patient's best interest for you to be the one who finishes and then teach or teach during the time so that the learner doesn't feel as though they've failed as much as to say i'm going to show you the way that you know to get us out of this problem and then you'll be better prepared to do it the next time absolutely absolutely i see a lot of this demonstrated um with surgeons when when uh i observe in in the operating room and you'll see um surgeons really good teachers uh quickly but not too quickly swoop in when they see going down the wrong path um you know okay i see that you're doing it this way but maybe we could take this approach instead just to make sure that that we're doing it right and do this expertly i think the folks that i've observed well and it's important to recognize when it's my clinical judgment and in theory because i've done it longer than you have my clinical judgment should have some validity versus no there's evidence that this is not right and that you are wrong and not not couch it is in well that's an interesting concept that you know that might work well you know you know we all know it won't work so be clear when you're saying this is proven to have been the way that this should have been done versus this is my opinion you will get smarter as we get further down this pathway but for now we're going to go with my opinion because that's where i'm comfortable absolutely i think actually your learners appreciate that rather than just the old pedagogue where we came in and said you know it's what the attending wants so that choice of antibiotics no the cdc doesn't say that but that's what she wants so that's what we write right absolutely um so let's see what else so one of my earliest dr ackerman one of my earliest mentors often said he who holds on the longest wins and was clearly stating that the importance of grit without really recognizing that he was talking about the concept of grit um thank you for this discussion and recognize that the need to have this as an ongoing learning training opportunity for faculty to have feedback on learning and development in this skill absolutely um it's a great it's a great area for faculty development and something that we've given to a couple of programs here but you know you can you can feel it yourself you know if you think back on how did my day go at my day of service attending and you know we had challenging things happen how did i deal with that from the learner's perspective we always think about it from the patient perspective but to give a little moment or two of self-reflection to say did i really walk the walk and talk the talk or did i just you know do the fastest thing to get out of there and now i need to circle back to these people to be sure that we've all digested what just happened definitely uh dr schlippner also said uh he was looking for the survey questions and answers or interpretation to the survey questions and i think dr mcallister really just wanted you all to see the foundation foundational questions for how they develop these concepts and how they assess these concepts and then there's descriptions within um the pdf that show you how to interpret um the scales is that correct dr mcallister right right the scores are there and the scores for the grit scale are pretty straightforward they just talk about percentiles that they've gotten back from large populations that they've given this score to so there's no again there's no right or wrong the scoring for the mindset is a little more complicated because they have to take into account the reverse scoring and so it'll take you a little longer to figure it out but you get the feeling that if you've answered that you know i stay with things i i have passion and i stay with it for longer periods of time i like challenges you're gonna you're gonna be higher on the grid scale and higher on the mindset scale and certainly if you feel like i believe my mistakes are a chance to learn then you're going to be dr dweck's friend she'll love you right and my inclination in the beginning when i was taking uh this ale was well i know what how i could answer to show that i have a little bit more grit but i got to be honest with myself because i'm not showing this to anybody so right there is this and it will change i mean again you were doing exactly what dr hoffman was talking about in his that you know depending on the situation you may be faking it to hope to make it so you fake it till you make it as a as a fairly successful um strategy but at some level you need to be honest with yourself and even better you'll get there faster if you're honest with the people who are working with you so that they can help you redirect whatever your your your error might be and hopefully be able to do it successfully in the nearer future rather than waiting to figure it out in the long run absolutely thank you so much dr mcallister and uh as a reminder to everybody else we have another session at five o'clock if you wanted to share with your colleagues or just come back um for a little bit more so enjoy the rest of your day um i hope you all have a successful one talk to you thank you.