Friday, August 8, 2014

True grit

In case you haven't noticed, a hot new topic in education is "grit." In order to reduce the long-standing 20% attrition rate of surgical residents, some say we should select applicants who have more grit or conscientiousness.

A recent paper in Surgery reported residents who dropped out of programs had decreased levels of grit as measured by a short-form survey. But due to unexpectedly low attrition rates in the surgical programs participating in the research, the study was underpowered to show a statistically significant difference in outcomes of high- vs. low-grit individuals.

It's hard to argue with the premise that choosing applicants with high reserves of grit might lead to better retention and performance of residents.

I blogged about this three years ago in a post called "Harvard says train residents and medical students like Navy SEALs."

Unfortunately, identifying who has grit will be much more difficult than simply testing those applying for surgical residency training.

Below is the eight-item grit survey, which is scored on a 1 to 5 Likert scale.

1. New ideas and projects sometimes distract me from previous ones
2. Setbacks don't discourage me
3. I have been obsessed with a certain idea or project for a short time but later lost interest
4. I am a hard worker
5. I often set a goal but later choose to pursue a different one
6. I have difficulty maintaining my focus on projects that take more than a few months to complete
7. I finish whatever I begin
8. I am diligent

The survey is rather easy to "game." You can take it online and see for yourself. Figuring out how to achieve a high grit score should be obvious. My grit score was 5 making me grittier than 90% of the US population.

You can avoid any uncertainty about passing the test by reading the paper which conveniently spells out which answers result in a high grit score. If the word ever got out that applicants to surgery residencies are being screened for grit, you can bet that only those with high "clueless" levels will score poorly. At least the clueless would be weeded out.

Attempting to assess grit in an interview would be equally hard for the same reason. Picture this conversation.

Program Director: Do you finish what you start?
Applicant: No, I don't.
Program Director: Are you a hard worker?
Applicant: No, I'm not.

Who is going to answer grit-related questions in a non-gritty way?

Here's another issue.

Despite rigorous background checks and thorough testing of physical and mental qualifications, some people selected for Navy SEAL or astronaut training fail to make it through.

Compare that to the process of selecting surgery residents, which involves sifting through several hundred applications for an average of four positions per year. Medical school grades and USMLE scores don't predict resident performance or success, nor do dean's letters and letters of recommendation from mentors.

Most programs conduct two or three interviews of 40 or 50 candidates for a total of maybe 45 minutes. Even if one luckily identifies a gritty applicant, she may not end up in the program. Because of the way the matching algorithm favors the applicant's choices, a program will almost never end up with all of its top candidates anyway. It's a bit of a crapshoot.

What can we do if we match applicants with average or low grit? An article in the Huffington Post says we don't know how to teach people to be more gritty. I think it's like common sense—a trait that cannot be changed or improved.

Assessing applicant grit levels might help, but the short-form grit survey is probably not the answer.


Anonymous said...

What does it mean if we are better than 4? I went into the wrong thing? I voted for reproductive endocrinology and prefered general surgery later on. Ok it was a toss up when I was a kid as to ob/gyn vs. general surgery but I ended up liking RE better.

artiger said...

Grit is like personality or bedside manner; you can't measure it, you only witness it.

I've probably suggested it before, one way around this might be to go back to the initial intern year where the newly minted physicians would rotate through various specialties, and then have a match. I know it's not going to happen, but I have to wonder if the attrition rate wouldn't go down that way.

Skeptical Scalpel said...

Anon, I have no idea what better than 4 means. Nor do I know how much grit is required to be a reproductive endocrinologist. I would assume one would need some grit. Would 3 be sufficient?

Artiger, I agree with your plan and that it will never happen. Training is too long now. Add a year? No way.

artiger said...

Scalpel, I was not suggesting adding a year. I was suggesting having everyone go through an intern year initially, then deciding on specialty, which would be one year less than today's specialties. Think about it. The first year out, the new intern is not matched but perhaps has a specific interest. Let's have them do a month of each: medicine, surgery, peds, ER, radiology (so they'll have a clue about how to look at films and when to order what), FP, critical care, perhaps anesthesia, and a couple of electives, with a month for interviews (maybe have all residency programs do interviews in the same month?). That way, all of the services still have slave, I mean first year labor, but new docs get a real flavor for things before making a serious life decision.

Yes, I know it will still never happen.

Geronimo MD said...


I’m a long time reader and fan of your blog.

Grit cannot be assessed by a survey. I wholly agree. As a military physician, my firmly founded opinion is that grit is essential to the practice of medicine. Grit is the elusive characteristic that carries the clinician through the challenges that exceed ordinary capabilities. You cite a paper that argues for surgical training to borrow aspects of SEAL training… I applaud any measure that would allow senior faculty and program directors to unilaterally shape their residents’ training, whether or not it bears any resemblance to the rigors of BUD/S.

The 2011 loss of 30 hour call for medical students and interns was a fatal blow to residency training, in my estimation. I count myself fortunate for having a 30 hour call internship before embarking on my operational career. While downrange, it is not at all uncommon to be woken at inconvenient hours of the night to tend to the wounds of war. If you don’t know how you function cognitively, physically, psychologically, and emotionally while sleep deprived, exhausted, hungry, cold, and pissed off, you’re behind the curve. While it isn’t any fun to work in such a state, or to work with people so challenged, it is decidedly less fun to be a patient expiring for want of any medical provider, let alone a tired one. American medicine used to be in such a place in the not so recent past, to hear the story told by my forbearers.

How often does disaster visit that requires sleep be sacrificed? The headlines recount a few – Katrina, Boston Marathon, Tropical Storm Alison, 9/11. No doubt there were physicians stretched beyond their ordinary limits for each of those ordeals. How often does it occur that a physician or surgeon must work beyond their ordinary limits for a patient whose ill begot fate failed to generate the attention of the press? I’d be willing to bet it’s on a monthly basis at least.

You sir, are a senior practitioner, and physicians like you taught me the practice. You know better than I why long hours and challenging training are essential, sir. My only question, sir, is why residency training standards were diluted and degraded at the behest of nurses, OSHA, and likely other “powers that be”, when you knew it was the wrong way. Why don’t modern program directors, department chiefs, make a stand? If there exists widespread agreement that the current methods don’t meet the standard, why pretend that they do? If you are a retired PD, you have a privileged position as not having to fear retribution. Use your bully pulpit to build consensus, unify the opposition and mount the attack.

Your SEAL post had a comment from a Man’s Greatest Hospital surgery program director who lamented the demise of training standards in the same fashion. I find it demoralizing that PD’s have been rendered impotent in the face of these trends. Obviously this will require a near unanimous front of PD’s and department chiefs. If your generation matriculates from practice without this trend being reversed, I believe it will be too great a task for my generation to overcome.

And for what its worth, I enjoyed the comments of TheTracker…

“The utter incompetence of your generation -- killing tens of thousands of patients every year with preventable errors secondary to the irrational systems, sloppily maintained, that you and your colleagues built up and managed.

Not to be blunt, but maybe while we're struggling to clean up your mess and catch up with the rest of the developed world, you could forgo your attempts to shift blame with anecdotes?”

This is pure unadulterated nonsense. I really can’t figure out what he’s talking about, but would venture the guess that he is a fan of checklists, timeouts, shifts that don’t exceed 12 hours and bubble baths. I don’t live in his world, and don’t want to. I am a doctor.

Geronimo MD said...

All doctors faced an attrition rate that exceeded BUD/S trainees matriculation to operational SEALs. Among aspiring physicians, 80-90% or more, are weeded out through undergrad prereq’s, MCAT, and the like. It should be an arduous, stressful endeavor to become a physician, just the same as it should to become a SEAL. Lives depend on SEALs’ and physicians’ capacity to demonstrate grit. Bearing that in mind, we should demand the same high standards and control over how we bestow the privilege of practice on the next generation. As it has been said many times, it is harder to stay in Ranger Battalion/SF Group/SEAL Teams than to become a Ranger/SF Soldier/SEAL. The same is doubtless true of surgery and medicine. Medical and surgical training programs should reflect that reality.

Anonymous said...

Better than 4 means our grit score was > 4. 4.19

Skeptical Scalpel said...

Artiger, your plan would add a year because no surgical board would give credit for a year of transitional internship.

Anon, OK, I see.

Geronimo, thanks for the comments. I can see you are passionate about the subject. I might want to post them as a guest blog. Would that be OK?

The work hours limits were created by the ACGME because at the time, they were concerned (so they said) that Congress would enact legislation that would have been even worse.

artiger said...

Scalpel, that's the idea, to get the boards for not only surgical but all fields to accept a transitional internship year. Health care in this country is so fragmented these days, it would benefit all of us to have exposure to things outside of our specialties. I dare say it might even result in fewer consultations, lower utilization, and lower costs. A man can dream.

ACGME got one thing right. It certainly would have been worse if it had been left to Congress. They just overdid it.

Skeptical Scalpel said...

You have a vivid imagination.

Geronimo MD said...


Repost as you see fit. Thanks.

chrisobgyn said...

What if grit can be learned? The following is from a very interesting article I came across on Harvard Business Review("How Resilience Works," by Diane L. Coutu

"Many of the early theories about resilience stressed the role of genetics. Some people are just born resilient, so the arguments went. There’s some truth to that, of course, but an increasing body of empirical evidence shows that resilience—whether in children, survivors of concentration camps, or businesses back from the brink—can be learned. For example, George Vaillant, the director of the Study of Adult Development at Harvard Medical School in Boston, observes that within various groups studied during a 60-year period, some people became markedly more resilient over their lifetimes. Other psychologists claim that unresilient people more easily develop resiliency skills than those with head starts."

Skeptical Scalpel said...

Chrisobgyn, thanks for the comments. I read as much of the link you posted as I could before I hit the paywall. Sounds interesting, but I note that it was written in 2002.

I concede that resilience might be able to be learned. But I have seen no evidence that anyone knows how to teach it or that anything new about learning or teaching it has appeared since 2002 or before.

I also agree that some children and concentration camp survivors must be resilient. Were they innately resilient or did they learn it? How can you possibly tell? Also, there are many children and concentration camp non-survivors who either weren't resilient enough or for some other reason did not come through intact.

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