I remember vividly my first patient as an academic Attending, it was many years ago now but it is still sharp in my memory and an interaction that I still reflect on. The patient was a 20’s year old male, post cardiac arrest, and presenting in sinus rhythm thanks to the great work of our prehospital providers. But he now was in need of a more definitive airway. I prepped the new intern on patient positioning, technique, medications, backup plans, confirmatory devices/methods, post-intubation management, and after all of that we proceeded. The new EM-1 approached the patient with great outward confidence and promptly and expertly converted the endotracheal tube into a nasogastric tube. The one phrase that sticks out in my mind was when I asked, “Are you in?” (Keep in mind this was before the days of video laryngoscopy) the not so confident response was “I think so…?” The patient did very well despite our initial attempt, no complications, no desaturation and I have reflected back on this interaction many times over the years. You see, I spent all my time in preparation and amazing instruction (if I do say so myself) but had I prepared my new resident for failure? Why wasn’t that a part of my plan/instruction? Was I afraid of even mentioning failure? I think it’s safe to assume that my intern reflected on that interaction as much as I did in the days to weeks that followed.
For some of our residents, the post-graduate training period may represent the first time in their life (professional or personal) that they experience a significant setback, mistake, or failure with negative consequences. This may take the form of a clinical decision (or indecision), interaction(s) with colleagues or patients, or just the stress of the training. The students and residents that we are lucky enough to mentor and teach are (for the most part) extraordinarily gifted and driven individuals, many of whom have never failed.
In her book Mindset: The New Psychology of Success Dr. Carol Dweck discusses how the mindset of the individual can be a great determinant of their success. She makes the distinction between was is referred to as a ‘Fixed’ vs a ‘Growth’ mindset. I can tell you that this book has helped me on numerous occasions to have more meaningful interactions with my students and residents (and Faculty), and has helped me to understand how help our trainees work through a setback in a much more beneficial way. In the book Dr. Dweck discusses that praising learners for their talent instead of hard work does not build mental toughness or confidence or help to develop resiliency, and can actually be counterproductive.
I suspect that many of us in medical education might recognize some examples of a Fixed mindset. That defensive pushback you encounter with a resident or student discussing a “miss” or the frustration/anger voiced after critical feedback on an evaluation or during a Faculty interaction. If a learner seems to give up with this type of feedback of feels that they are “no good” this should be an indication to us of the mindset (at that time) of the learner. Developing a growth mindset will take time and my hope is that we view it as a wonderful opportunity to build trust with our learners and demonstrate to them that their intelligence and talent do not determine their worth. The “Growth” mindset is one that welcomes challenges and opportunities and the “Fixed” places more value on praise and accolades.
After reading existing work on this concept in other fields I have tried to incorporate this into our resident and student curriculum. I stopped trying to ” win” the crucial conversations that I was having with my residents and students and have instead began to listen in order to understand their mindset. I guess you would have to talk to them but I feel that our interactions are much more meaningful and understanding.
Bo Burns, DO FACEP
George Kaiser Foundation Chair in Emergency Medicine
Associate Professor & Program Director
Department of Emergency Medicine
University of Oklahoma School of Community Medicine