- Email: [email protected]
The Core of Competence: It’s a Matter of the Heart
PRESIDENTIAL ADDRESS
The Core of Competence: It’s a Matter of the Heart John D. Mellinger, MD Southern Illinois University School of Medicine, Springfield, Illinois Let me begin by saying what I know each of us in this audience recognizes: The privilege of my being here today is a function of the undeserved blessings in my own life that have come through others. In this regard, I would like to highlight the role of several of my personal and professional mentors. On the professional front, I would like to thank Bud Hurst, a general surgeon I met in my undergraduate and medical school years, who taught me to view medicine as a ministry and modeled that one’s service through our profession can and should be a direct expression of our most deeply held convictions and values, which as you will see is one of the themes I hope to pursue with you today. I would also like to thank Jeff Ponsky, who showed me that professional and educational excellence go hand in hand and that prioritizing one’s love for family could be integrated into a busy and productive professional life. I would also cite my residency program director, Bill Passinault, who showed me what it meant to practice the highest ethics in one’s relationship with patients, colleagues, and trainees and who demonstrated that humility and selfsacrifice were foundational disciplines for educational leadership. Tom Gadacz and Bruce MacFadyen, my chairs at the Medical College of Georgia, gave me the opportunity to make education a meaningful and central academic focus of my professional duties. Bruce also introduced me to the world of ministry through international medical education, which has been one of the richest and most humbling experiences of my career. More recently, Gary Dunnington, David Rogers, Reed Williams, and Hilary Sanfey, along with our entire educational team at Southern Illinois University (SIU), taught me the value and discipline of educational scholarship and have become dear colleagues and friends. Finally, the members of this association and its leadership teams over the years, including our past presidents and our current executive team, support staff, and board, have been tremendous mentors in my own career path. I leave out many in this quick review, but would certainly not be here today and would have nothing Correspondence: Inquiries to John D. Mellinger, MD, Southern Illinois University School of Medicine, PO Box 19638, 701 N, First St, Springfield, IL 62794-9638; e-mail: [email protected]
meaningful to say to you today, were it not for these and others that have invested in me by their examples and by sharing in community with me. I must also say thanks to my wife, Elaine, and to the family I share with her, for their support and love. What they have meant, continue to mean, and will always mean in my life is beyond words. Given that, perhaps a quick story will illustrate my heart. You may have heard the story of the corporate chief excecutive officer (CEO) who pulled into a gas station one day with his wife. An attendant came out to pump gas for him while he ran in to use the rest room. When he came out, he found his wife involved in an animated conversation with the attendant. As they pulled away from the station, he asked his wife what she had been talking about with the man, and she replied that he was an old boyfriend from high school days. Somewhat smugly, the man said, “I bet you’re thinking you are glad that you married me, the CEO, and not the guy pumping gas!” To this his wife quickly replied, “Actually, what I was thinking was that if I had married him, he’d be a CEO and you’d be pumping gas!” Elaine, thank you from the bottom of my heart for being my best friend, my love, my joy, my partner, and my companion in the journey of life. Anything I have been blessed to achieve has been through your support, encouragement, and partnership. You are a joy to me. Thank you. There are many things I could highlight and review with you today about our society and its engagement on various fronts related to medical and surgical education and that would be a typical focus for this address. I have, however, chosen to leave those important items to our board and business meetings and to the discussions that our excellent program will stimulate during our time together here in Chicago. Let me here say also a special thanks to Karen Deveney and the program committee for their outstanding work on putting the educational feast of these few days together for us. What I would like to do instead with our time together this morning is speak to you from my heart, and I would like to respectfully ask that you open yours to me, if you are willing to trust me with that for the next 90 minutes (just kidding…I wouldn’t listen to myself for that long either). If you are so willing, I would like to speak from
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that foundation and say something that I hope would stimulate us all to reflect together on some issues that I trust are truly of ultimate importance to what we do as surgical educators, and in fact, as human beings. In the format of an educator, I would like to then begin by sharing with you what I hope to demonstrate. First, I want to suggest that as educators, we live in challenging times, and this can easily distract us from what is of greatest importance. Secondly, I would like to suggest that character or virtue is our learners’ greatest need, and is our greatest contribution to their development. Third, I would like to focus briefly on the “how” element, looking at how disciplines and habits can enable us in this effort, both personally and professionally. Finally, I would like to suggest that the core of our learners’ competence, and the core of our own competency as educators, is what we choose to value or ascribe ultimate worth to, and then pursue with discipline. Modern prophets have characterized our contemporary situation well, including as pertains to medical education. Einstein1 said, “Perfection of means and confusion of goals seem…to characterize our age.” Eliot2 made the point that current human endeavor had oriented itself to finding “… systems so perfect that no one will need to be good.” “The system is the solution,” seems to have become a modern mantra, and not just as an advertising slogan for Ma Bell and AT&T. Lewis, commenting on the differences between how historical thinkers and modern ones addressed issues of fundamental importance, pointed out that, “For the wise men of old, the cardinal problem had been how to conform the soul to reality, and the solution had been knowledge, self-discipline, and virtue. For…applied science…the problem is how to subdue reality to the wishes of men; the solution is a technique.”3 Lewis4 further captured the limits of a purely technical approach to societal development when he pointed out that, “You cannot make men good by law, and without good men, you cannot have a good society.” If we look at this mindset as expressed in current medical education, we can see some significant parallels. On the positive side, there is an appropriate focus on outcomes, an increasingly detailed orientation to performance, and an ongoing quest for meaningful metrics that might help us predict performance and outcomes. However, to use Einstein’s phrase, this seems to have facilitated a world very preoccupied with tools, and perhaps distracted or even confused about goals. Let me illustrate briefly. If one looked at the dashboard of an early generation Volkswagen, one would find there is a speedometer, and no other tools oriented toward measurement to occupy the driver’s attention. Conversely, one would find a rather large area of window or interface with the outside world, allowing a direct, rather than metricdictated and indirect, interaction with it. If one compared this to a modern or contemporary Volkswagen dashboard, one would note there are quite a few more measuring tools e4
occupying the driver’s surrounding physical and attentional space, and correspondingly there is considerably less room to directly interface with the surrounding environment through windows and windshield. If we take this a bit further to the cockpit of a modern jetliner, we would find that the measurement systems relaying information about the surrounding world to the pilot have literally taken over the occupant’s space and have in fact necessitated a very limited and arguably superfluous residual window to the visible outside world as those systems have proliferated. Is there perhaps the danger, in such a progression, of distraction by tools that leads to unintentionally dangerous interactions with the outside world? (picture of driver with cell phone)… I think the answer is yes. So what I mean to suggest by this perhaps crude example is that while tools and metrics can offer us increasing information about, and potential for control over our environment, allowing increasing speed, comfort, efficiency, and safety, they often become cognitively dominant for us in doing so and have the potential thereby to distract us from the most important aspects of our interaction with the world around us. As an example of such, the crash of Air France Flight 447 into the Atlantic Ocean in 2009 was ultimately attributed to the inability of the flight crew to cognitively override confusing data presented by the plane’s control systems when the autopilot was disabled by ice build up on the plane’s Pitot tubes (used for airspeed measurement). A 30,000 ft fall into the ocean over 3 minutes was the result, with the haunting black box exclamation from one of the pilots shortly before impact, “We are going to crash, this is unbelievable!” Now if I were to bring this theme home to our world as medical and surgical educators, I would highlight some of the increasingly sophisticated measurement strategies and related tools that have evolved in the past decade. These would of course include the core competencies as illustrated in the Accreditation Council for Graduate Medical Education and CanMEDS iterations, and the more recent milestones project. I want to emphasize that I believe these represent outstanding efforts by very thoughtful colleagues who are clearly working to help us improve the quality of our learner assessments and our training programs. At the same time, when one adds up the elements of measurement and assessment entailed in these efforts, alongside contemporary financial and curricular mandates, one ends up with a daunting array of pressures that, while all best-intended, make the jobs of the people in this room seem overwhelming. In prior work at SIU, ongoing compliance with the first iteration of the competencies was calculated to have profound effects on resident workload, recurring faculty workload, and especially the workload of program coordinator support staff. Accordingly, for the older members of the audience, the current status of medical education may bring back memories of a piece of popular culture prophecy from 1970, Alvin Toffler’s Future Shock. In that work,
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Toffler5 defined the condition his title described as a psychological state of individuals and entire societies as a perception of “too much change in too short a period of time.” For many in the audience today, Toffler’s projections regarding the pace of change in graduate medical education ring strikingly true. Going back to our automobile and cockpit analogy, the question I would like to pose for our consideration this morning is how might our current milieu, as it pertains to graduate medical education in the United States, while providing us with a wealth of detailed information regarding our learners and their progression, distract us from more important and fundamental tasks? Perhaps more importantly, what might those tasks be, and how might we show care to address them in the midst of our evolving and potentially distracting educational ambiance? To harken back to the insights of the previously quoted modern prophets, how do we remember the goals amidst the proliferation of tools or means? How do we produce a product recognized as “good” while the systems within which we must function become increasingly complex? How do we not end up joining the Flight 447 copilots in offering our statements of disbelief as the challenges of current graduate medical education (GME) threatens to stumble under its own weight, while we carefully mind more data points than ever in our attempt to keep the ship on the right course? In answer to the question of priorities, John Tarpley shared with this group in his 2008 presidential address that according to American Association of Medical Colleges Chief Medical Officers, the greatest challenge they faced was “increasing the professional behavior of our faculty.” In his 2007 exit interview published in the Accreditation Council for Graduate Medical Education Bulletin, David Leach, referring to Parker Palmer’s influence, commented that “…we teach who we are.” He further elaborated that “…although (the residents) journey is full of external drama, it actually proceeds from the inside out and is about character development” (emphasis added). “Residents model behaviors and values; they especially value faculty who ‘live divided no more,’ i.e., whose external behavior is always aligned with deeply held inner truths.” To further highlight that these issues of character on the part of educators, and character development on the part of our learners, is in fact of very current importance to our thought leaders, I would highlight Carlos Pellegrini’s Presidential Address from last fall’s American College of Surgeons Clinical Congress, in which he outlined that surgeons of the future will need a moral compass to navigate changes in the profession. Perhaps even more poignantly, in a book recommended to me by Reed Williams, and which some of you in the audience have read, Donald Schon’s “Educating the Reflective Practitioner,” Schon highlights the implications of our professional failures to address these issues of values and ethic. He states, “When professionals
fail to recognize or respond to value conflicts, when they violate their own ethical standards, falls short of self-created expectations of expert performance, or seem blind to public problems they have helped create, they are increasingly subject to expressions of disapproval and dissatisfaction… public, radical, and professional critics voice a common complaint: the most important areas of professional practice now lie beyond the conventional boundaries of professional competence,” (emphasis added).”6 I need to digress for a moment here and acknowledge that much of what we know of character is developed long before we match a resident, or for that matter are hired ourselves as faculty members. I am reminded of a biannual performance review faculty meeting I chaired some years ago at a noble and now since twice renamed institution in the South. In that meeting, we were struggling greatly with our collective assessment of a senior resident who, in a scenario perhaps too familiar to many of you in the audience, had transferred into our program after preliminary training elsewhere with good reviews, only to prove to have some challenges with his work ethic, and in particular, as a senior resident with how he delegated or “dumped” on his colleagues. After debating (again) for some minutes on the challenges, the largely ineffectual results of counseling and “chair time” with myself as program director, and our collective ineffectiveness in facilitating a change in this trainee’s performance, a faculty member piped up from the back of the room with one of those pithy pieces of wisdom that I need John Tarpley to help me say properly. I quote: “Listen y’all, this boy’s momma screwed up and you ain’t never goin’ to make him right!” This was perhaps the most profound statement I have heard at a faculty meeting in 25 years! As further reinforcement for the veracity of this challenge for all of us as adult educators, I would highlight work done by my colleagues at SIU. In a 30-year review of resident performance problems, Williams showed that while we identified 82% of problems in the first year of training, and 94% by the third year, 88% of residents identified with problems in the course of their training had persistent problems at their completion of training. Problems that were either solely or in part related to professionalism issues were the most prevalent in that analysis.7 Having recognized this challenge of trying to address character development in adult learners as a real one, I would submit that we cannot afford as a profession, and as a generation of educators, to leave unaddressed Schon’s “most important areas of professional practice” simply because they seem to lie beyond our current “boundaries of professional competence.” What we need to do is not acquiesce under the weight of our weaknesses and failures; rather, we need to look deeper into our nature and its potential for reformation, for renovation, in order to chart our course. I would like to pursue this in 2 phases. First, I would like to examine some of the features of our human nature that
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we all recognize experientially, i.e., that we can’t not know to be true. I will highlight here a superficial summation of some of the work of a recently deceased Professor of Philosophy from the University of Southern California whose work has had a profound influence on my thinking in my midlife years. Willard8 points out that all of us make choices from an inner world of thoughts, emotions, and will that has been variously described through history as our heart, mind, spirit, thought-life, consciousness, etc. For the purposes of our discussion today as reflected in my title, I will use the word “heart” for this element of our nature, as despite its anachronistic anatomical limitations for us as moderns, it keeps me from thinking of this delineation of our fundamental self and identity as a purely materialistic process of neuronal processing. I would hear interject, and I hope very humbly, that if there are any rugged materialists in the audience, who might define our “heart” or value issues as purely neuromechanical byproducts of the chemistry of our brains, I myself cannot embrace that mindset for a number of reasons. Not the least of these is that with our contemporary understanding of DNA, a purely materialistic interpretation of reality would require that I believe matter can produce information, and no empiricist has ever seen that. But I digress and don’t want to sound polemical beyond my credibility. The point of this issue of our “heart” is that we all see and interpret reality from this inner world. Furthermore, our responses to our environment from this inner realm, including and especially our creative choices of will, are amongst the most important things about us—our character. After considering these features of our nature, I would like to examine disciplines and habits, and how they can help us address the daunting challenge of character formation and reformation, even in our relatively ossified status as adult learners. It is important before I go on to spend a moment reflecting on some challenges we have in this era regarding how to process our handling of this issue of values, character, and the related theme of truth. In our postmodern times, we have largely adopted in the west a concept of truth, at least as practiced in the highest realms of academia and our sociopolitical structures, that views truth as at best a relative term. We like to think we’ve escaped this in the sciences, but a quick review of the medical literature and the position and especially advocacy statements of our esteemed professional societies reveals much that is born of self-service rather than a rigorous standard of evidence and logic. The sound bite thinking and “spin” rhetoric that categorizes some of our most important collective social dialogues, such as political campaigns and the reporting of our news media, is a reflection of this. Secondly, thinking ourselves productive because we are busy, large segments of our society, including perhaps much of our profession, have largely abandoned reflective disciplines, despite the fact that these have been some of the most fundamental activities for geniuses and other e6
productive humans over the course of our history. In addition, we have, in the west, especially in Europe and increasingly in the United States, embraced secularism as a key feature of our worldview. While I would perhaps be abusing my privilege of the podium by turning this discussion into one that would be seen as “religious” in orientation, I do want to highlight that this movement in thought has profound implications for issues such as hope and accountability, to which I shall return in a few minutes when we consider the theme of character reformation as illustrated in addiction science. Nietzsche’s idea that he had killed God by rendering him useless in his philosophy, and that the moral “ubermensch” or “superman” was someone who did as he pleased out of moral independence was not just philosophic philandering, but provided an intellectual foundation for the actions of twentieth century pogroms and genocides and informed the self-described mindsets of serial killers such as Ted Bundy, along with a host of less infamous followers of self-ordained moral authority. Finally, our consumerism in the west has become our buffer against serious reflection on these challenges. As Gary Dunnington’s son Kent has suggested in a powerful book on addiction and what it teaches us about modern times, our spending of money, and I might add including on health care items that do not add value to our patients’ lives, has become our means of “…distracting ourselves from the frightening possibility that we really don’t know what is worthwhile.”9 To that I say a personal, “ouch,” and thank you, Kent. Please bear with me here for a moment. I realize that’s a lot to cover in a talk on GME, and I am no philosophic expert or trained cultural critic. What I am trying to suggest is we must not lose the ability to reflect meaningfully on our own liabilities and blind spots in the era in which we live if we are to prepare our learners to understand what is important and pursue it with diligence. David Brooks talked about our collective societal failure to accomplish this for the best and brightest of our next generation in a New York Times piece from May 24, 2012, and referenced by Keller10 in his excellent book on work and its meaning, “Every Good Endeavor.” Brooks describes a survey a Stanford professor did of students and recent graduates to evaluate why so many top graduates of upper academic tier universities were going into jobs in finance and consulting. It was found that students chose jobs in one of 3 categories: financial reward, service to society, or the “cool factor,” meaning something like a job at Google. What was disturbing was the general lack of an ethic that allowed work to be interpreted as character founded and of meaning based on one’s gifts and sense of calling to serve the common good. Brooks outlines that a large segment of the “community service” subset appeared to be comprised of individuals who chose the field not for its relevance to their sense of giftedness or personal purpose, but because, “Community service has become a patch for morality.
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Many people today have not been given vocabularies to talk about what virtue is, what character consists of, and in which way excellence lies, so they just talk about community service.” One wonders parenthetically if some of our current medical students are looking for a parallel sense of meaning or purpose for their labors in a vocabulary vacuum such as Brooks suggests, as evidenced by the surging interest in global health. He continues, “…around what ultimate purpose should your life revolve? Are you capable of heroic self-sacrifice, or is life just a series of achievement hoops? … You can devote your life to community service and be a total schmuck. You can spend your life on Wall Street and be a hero. Understanding heroism and schmuckdom requires fewer Excel spreadsheets, more Dostoyevsky and the Book of Job.” I would join Brooks in suggesting that we will not resolve the fundamental needs of our resident learners by continuing to polish and refine our GME spreadsheets but by focusing on their unique gifts and how they might best be used to make the world a place of more common healing, grace and peace. So back to our inner world—do we really think (a la the critical comment I shared earlier that my Southern colleague made in regard to my former resident’s maternal influences) that this inner dimension of our personhood can be reformed? I would concur with Willard that virtually all influential figures in history have felt it can, for better or for worse, even at a societal level. Witness Nazi Germany, Cambodia, the rise to independence of India, and the Solidarity movement in Poland, to name a few. Or witness William Wilberforce’s lifelong effort to bring down the slave trade in Great Britain in the late 18th and early 19th centuries, or the civil rights’ movement in our own country. In each of these instances, individuals of deeply held internal convictions, constructive or destructive, influenced the course of whole societies and their collective hearts or soul. The concept that this inner world can be changed lies behind all meaningful events to improve our human situation, both public and private, again as Willard has pointed out. I will give here a brief example from history. My outline here will be to follow what Steve Sample, President of the University of Southern California, has recommended. In his book The Contrarian’s Guide to Leadership, Sample suggests you shouldn’t read things that aren’t at least 400 years old, as that is a reasonable test of a work’s enduring value.11 This is attractive in that it shortens one’s reading list considerably. I will apply this principle in several of my following developments. First, in Jesus’ Sermon on the Mount, he highlights that it is a rightly ordered inner world that is essential to right outward behaviors. For example, he highlights that to pretend to be outwardly what we are not inwardly is highly destructive and dangerous, that right living has a preservative and illuminative impact on society, and that accordingly, we must manage our inner motives and thoughts and not just our outward behaviors for
appearance’ sake. Hence, our speech should not be manipulative but be an accurate presentation of our position, retaliation replaced by concern for one’s opponent and service to them can be transformational, and philanthropy, if to be about others, should be private and not public, and so forth. Without question, these ideas contrasted greatly with prevailing norms in the Greco-Roman world and profoundly affected the subsequent course of western and world history. If we were to extrapolate this underlying principle to the realm of GME, we would distinguish between appearance management mode and motive mode. If we are focused only on the former, we might ask whether a resident completes their records and follows handoff protocol as a competency and compliance measure and check the according box on their evaluation form. In the latter mode, however, our concern would be whether the resident fundamentally desired others to have the information they needed to optimally care for the patient. If we can address the motives, the behaviors will follow. Let me parenthetically state here that one of the things the milestones are working to helping us articulate is indeed focused at this “heart” or motive level of assessment. For example, on the professionalism competency and Care for Diseases and Conditions Practice Domain, the resident must demonstrate qualities such as honesty at level 1, empathy at level 2, integrity at level 3, and self-sacrifice for the good of others at level 4 (page 8 f Milestones). While measurement can be a challenge, this type of defining of qualities that must underlie behavioral competence is, in line with the arguments I am making, of real potential help to us as mentors and teachers. I would now like to move on to how this type of teaching, or character reformation, might be accomplished. Willard suggests that renovation of our inner world requires a vision of our goal, the intention to pursue it, and the means of pursuing that goal, which involves behavioral disciplines. The integration of our thoughts, emotions, and will, and of our physical body in the spectrum of these domains of vision, intention, and means, touches on all aspects of who we are as humans. I would submit that our learners can achieve the vision element through effective role modeling, which then invites their intentional pursuit of the character or quality they see in us as educators, and the behavioral discipline aspect through our coaching efforts, giving them practices and actions to deliberatively pursue. This latter element is much as we might advise them to do for technical skills training. Kent Dunnington in his Addiction and Virtue, to which I have previously referred, reflecting on Aristotle, offers the following: “(mental assent to an idea that something is good or right) must be translated in to ‘heart knowledge’ (emphasis added) as well. The student of right action must come to embrace in an effective way the actions that he has come to believer are right. And this takes time and practice, which is to say that this takes habituation,” (emphasis added).9 One of the duties of
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the educator, accordingly, is to demonstrate concrete behaviors that our learners can adapt in their own disciplined pursuit of competence, and which allow them to translate their will and intention into behaviors that, over time, habituate their intellectual and volitional efforts into “heart knowledge,” allowing Aristotle’s translation to occur. As an example of how this might be done, let me briefly describe a project I did while at the Medical College of Georgia and have since shared with audiences in several other academic centers, all of whom seemed to find it meaningful. In an effort to operationalize the competencies, I sat down with our residents in a sort of “focus group” and asked them who on the faculty best embodied each of the 6 core competencies as they (the residents themselves) defined them. I then went, using this appreciative inquiry approach, to each of the identified faculty and interviewed them regarding what personal disciplines they followed that they felt had helped them achieve a high level of performance in that particular competency domain. So, for example, the faculty member identified as demonstrating the best practice-based learning skills identified his experiences of being humbled by his shortcomings in patient care as a resident and learned to respond to those situations by dutiful study to allow himself to become an expert on the topic in which his shortcoming had been made apparent. He then would seek an opportunity to teach students or others on the topic as a way of sharing what he’d learned and testing his depth of understanding. In those areas of expertise he so leveraged, he subsequently sought to maintain a current body of knowledge through continued focus on any new information on the topic that the literature would offer over time. His “failures” thus became, through a disciplined approach to what we would call practice-based learning, areas in which he became adept and, in fact, became a resource to his learners and colleagues. The importance of such disciplines and habits in our behavior has been summarized recently by Duhigg12 in his book, The Power of Habit. I recently read this work after encouragement by my dean, Kevin Dorsey, as we discussed how to train our students in professionalism. Duhigg summarizes that habits dictate 40% of our behaviors, can be mapped neurophysiologically, and can lead to selfdestructive behaviors such as addiction. Studies at Massachusetts Institute of Technology on rats demonstrate that habit development involves neurophysiological “chunking” at the level of the basal ganglia, which in a fashion parallel to our understanding of skills learning theory, or perhaps even the cortical plasticity work that Dimitri Anastakis has presented at Surgical Education Week in the past, frees up cognitive space from being immobilized by endless behavioral choices. This is critical not only to how we brush our teeth or park our car but to our behaviors that would be seen as representative of our fundamental values and character. Kent Dunnington, in this case amplifying on e8
Aquinas, outlines that “A life that is perpetually involved in dealing with moral crises of action will inevitably be a failure. The problem with such crises, for Aquinas, is not that they are irresolvable, but rather that they tax the moral agent. The goal of moral training is the formation of moral habits, because habit names the possibility of acting well without the exertion that is required of deliberative practical reasoning,” (emphasis added).9 In Duhigg’s analysis, there is a “habit loop” that involves a cue or stimulus, a routine that is learned and constitutes the behavioral element, and a reward for this behavior. The key to change in his analysis involves substituting behaviors or routines in response to the stimulus that still are reinforced by the reward. In analysis of individuals and groups who have successfully pursued change, several important lessons have been noted. First, there needs to be meaningful belief that change can occur. Secondly, communities make change believable. Note here our earlier comments on the hope and accountability, and the use of Alcoholic Anonymous’ principles of a “Higher Power” and sponsors. Third, willpower is self-reinforcing, and therefore has a developmental or compounding aspect, the corollary of which is it can be fatigued. Finally, keystone habits can have contagious effects, as is seen with contagious culture change in organizations, or I might add in my own observations, successful remediation efforts with residents —one small “win” often brings in its wake a self-reinforcing capability to constructively engage in other disciplined behavior with compounding success. In this latter regard, Duhigg shares some wonderful stories about experiments with willpower. For example, many of you have seen humorous videos of the studies done on small children asking them to try to avoid eating marshmallows with the promise that if they did so discipline their oral intake for the defined time of the study, they would be given more marshmallows at the end. Those children, who at a young age could accomplish that brief exercise in delayed gratification, were found on delayed follow-up to have an average Scholastic Aptitude Test score 210 points higher than the children who couldn’t wait (more predictive than intelligence quotient) and were more popular and less likely to use drugs as teenagers. Conversely, in an adult study where subjects were asked to avoid eating radishes vs warm chocolate chip cookies (a poor pre-lunch illustration, I understand), and were subsequently asked to work on a puzzle that was not solvable (unbeknownst to the subjects), the cookie-resistors worked 60% less long on the puzzle, suggesting they expended more of their “willpower bank” resisting the more inviting food option. These studies, along with the keystone habit concept, offer an interesting model of behavioral conditioning and fatigue that goes well beyond our calculations of hours worked and may help explain professional and moral failures by normally effective practitioners in ways that go beyond simple sleep cycle analyses.
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So what kind of disciplines might we then suggest to our trainees, or better yet model for them, which will instill in them a vision for what they might become at the level of their inner worlds, which will invite their personal commitment to invest in that goal intentionally, and which will practically equip them, by our earnest if obviously imperfect examples, with behavioral disciplines that they might imitate to begin a process of habituation that equips them with those skills and behaviors as relatively automatic responses? Again, what I am proposing is not dissimilar to what we would preach to them in technical skill development and the deliberate practice we espouse to the end of their development in that area. What it will require is a different level of intimacy and transparency with them regarding our own hearts, but if David Leach was right about what they want from us as teachers, the results could be refreshing, if not revolutionary. Some of the personal disciplines I have personally found most helpful in these regards, and which when I do it well (which is inconsistently at best), are as much in action at M&M’s or over a pancreatic resection as they are over a cup of coffee at a semiannual “mentoring meeting,” include the following: open gratitude, acknowledgment of failure, purposeful humility (which often equates to sound judgment), focus on the needs of others, acknowledgment of false appearances when I have wrongly facilitated them (e.g., “the literature says…” when I am only aware of one article and don’t know the reference), solitude (which can help allow a space to listen and become sensitive in all the above areas), and reflective reading that crossexamines my self-assured and self-centered behaviors (here I would say the 400-year rule really applies well—it’s easier to see your flaws when you tolerate the perspective of an age other than your own). Finally, and again I owe my thought here to Dallas Willard, once you get started on this, there is a potentially endless curriculum in which one can engage. An acquaintance of Willard’s tells the story of watching him finish a scholarly philosophic talk at the end of which a relative novice in the audience stood up and rather naively critiqued Willard’s presentation. Willard thanked him for his comments and offered no rebuttal. The friend approached Dr. Willard after the session and asked why he hadn’t totally refuted and embarrassed the brash and uniformed critic in the audience. Willard’s response was that he had become convinced he needed to work on the discipline of not always having the last word, and felt he had been provided a good opportunity to practice just that. What our trainees wouldn’t give for some surgical educators with that spirit, myself included! Perhaps that will be a topic for a new faculty development session that I could certainly benefit from personally! Well my friends, you have listened well, and I thank you for that. In review (and I remember here that I am speaking to a group of wonderful educators, including many of my own mentors, so forgive my pedagogy), I have suggested that as educators, we live in challenging times. There is a
danger inherent in our era that we will be distracted from what is most important, and I have further outlined that what our learners need most from us is the demonstration of character and virtue lived out from rightly ordered inner worlds in the context of our daily professional duties. I have suggested that what ancient thinkers and modern science have taught us about habits as engendered right actions can help us in these regards. I have also argued that personal disciplines “of the heart” can both help us grow in an ongoing, individualized, and lifelong fashion and can allow us to demonstrate for our students the means by which they may pursue the progressive ordering of their inner worlds as necessary foci of renovation if they are to be effective caregivers in the challenging profession which we share. I have argued that we have special liabilities in these efforts linked to our contemporary societal worldview and need to be far more self-critical in these regards if we are to really contribute as luminaries or reflectors of truth, rather than educators “du jour.” I now offer one final thought. I suggest to you that what our inner world reflects, and therefore becomes that alone which we can truly model and teach someone else, is what we ourselves supremely value, or if you will, what we “worth-ship.” I recently heard the true story relayed of a man who became somewhat unexpectedly and lavishly wealthy. He hired a life planner to help him decide what to do with his precocious prosperity. After spending a considerable amount of time with the man and his spouse, the life-planning coach walked to the white board and drew a box on it. He said to the man and his wife something like this: “I have learned much of your life, your interests, your goals, and your passions. I am prepared to help you decide how to pursue those things with the resources you have. But there is one thing, the most important thing, which you have not yet told me. I need to know what of all that you value most, because that determines everything. Tell me what to put in the box.” Colleagues and members of the Association of Program Directors in Surgery, my own mentors and friends, and yes, the question I ask of my own heart, what is it that our generation of surgical educators wants to put in the box? What is our highest value? Is it our appetites for fulfillment, influence, or reputation? Could it be our curriculum vitae, our retirement plan, the number of cases we’ve done, or the profitability of our sections, divisions, or departments? Could it truly be our service to others and especially our trainees, fulfilling our societal mission to “support program directors in optimizing the training of tomorrow’s surgeons?” Might it be a relationship with our Maker that profoundly and positively impacts our every relationship on earth? I cannot tell you what answer you may offer to that question, as our nature as humans dictates that we must each answer in our own hearts. I do close, however, by encouraging us individually and collectively to answer it, and to live out our answer with all the integrity we can muster, and with much humility for our failings. I would strongly encourage us as we contemplate this to evaluate our answers by 2 important criteria: are our answers timeless, and are they
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relational? I would suggest that answers we offer that fail in those regards will lead to disappointing results, as they are likely to be dictated too easily by convenience and our propensity to the default of self-interest. The answer we give to this question individually and collectively defines vision, orients intention, and provides a template for disciplined behavior through which we can bring our outer world into an integrated expression of our inner reality. For our learners, leading lives that exemplify this, and which demonstrate those disciplines as expressions of a rightly ordered inner world, is the greatest contribution we can offer them. This is a life of integrity. This is the call for the educator of our time. From the bottom of my heart, I thank you, my colleagues and friends, for the privilege of serving as your president and for the privilege of your podium. Blessings on each of you, and on this fine organization, for years to come.
3. Lewis CS. Illustrations of the Tao.The Abolition of
Man. New York: Collier; 1955. 4. Lewis CS. Mere Christianity. New York: MacMillan;
1952. 5. Toffler Alvin. Future Shock.
New York: Random
House; 1970. 6. Schon Donald. Educating the Reflective Practitioner.
San Francisco: Jossey-Bass; 1987. 7. Williams RG, Roberts NK, Schwind CJ, Dunnington
GL. The nature of general surgery resident performance problems. Surgery. 2009;145(6):651-658. 8. Willard Dallas. Renovation of the Heart.
Colorado
Springs, CO: NavPress; 2002. 9. Dunnington Kent. Addiction and Virtue. Intervarsity
Press; 2011.
REFERENCES
10. Keller Timothy. Every Good Endeavor.
1. Einstein Albert. The common language of science.
Broadcast for Science. Conference; September 28, 1941. 2. Eliot TS. Choruses from the rock. In: Collected Poems
1909-1962. New York: Houghton Mifflin Harcourt; 1963.
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USA: Penguin
Group; 2012. 11. Sample Steven B. The Contrarian’s Guide to Leadership.
San Francisco: Jossey-Bass; 2002. 12. Duhigg Charles. The Power of Habit.
New York:
Random House; 2012.
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The Core of Competence: It’s a Matter of the Heart John D. Mellinger, MD Southern Illinois University School of Medicine, Springfield, Illinois Let me begin by saying what I know each of us in this audience recognizes: The privilege of my being here today is a function of the undeserved blessings in my own life that have come through others. In this regard, I would like to highlight the role of several of my personal and professional mentors. On the professional front, I would like to thank Bud Hurst, a general surgeon I met in my undergraduate and medical school years, who taught me to view medicine as a ministry and modeled that one’s service through our profession can and should be a direct expression of our most deeply held convictions and values, which as you will see is one of the themes I hope to pursue with you today. I would also like to thank Jeff Ponsky, who showed me that professional and educational excellence go hand in hand and that prioritizing one’s love for family could be integrated into a busy and productive professional life. I would also cite my residency program director, Bill Passinault, who showed me what it meant to practice the highest ethics in one’s relationship with patients, colleagues, and trainees and who demonstrated that humility and selfsacrifice were foundational disciplines for educational leadership. Tom Gadacz and Bruce MacFadyen, my chairs at the Medical College of Georgia, gave me the opportunity to make education a meaningful and central academic focus of my professional duties. Bruce also introduced me to the world of ministry through international medical education, which has been one of the richest and most humbling experiences of my career. More recently, Gary Dunnington, David Rogers, Reed Williams, and Hilary Sanfey, along with our entire educational team at Southern Illinois University (SIU), taught me the value and discipline of educational scholarship and have become dear colleagues and friends. Finally, the members of this association and its leadership teams over the years, including our past presidents and our current executive team, support staff, and board, have been tremendous mentors in my own career path. I leave out many in this quick review, but would certainly not be here today and would have nothing Correspondence: Inquiries to John D. Mellinger, MD, Southern Illinois University School of Medicine, PO Box 19638, 701 N, First St, Springfield, IL 62794-9638; e-mail: [email protected]
meaningful to say to you today, were it not for these and others that have invested in me by their examples and by sharing in community with me. I must also say thanks to my wife, Elaine, and to the family I share with her, for their support and love. What they have meant, continue to mean, and will always mean in my life is beyond words. Given that, perhaps a quick story will illustrate my heart. You may have heard the story of the corporate chief excecutive officer (CEO) who pulled into a gas station one day with his wife. An attendant came out to pump gas for him while he ran in to use the rest room. When he came out, he found his wife involved in an animated conversation with the attendant. As they pulled away from the station, he asked his wife what she had been talking about with the man, and she replied that he was an old boyfriend from high school days. Somewhat smugly, the man said, “I bet you’re thinking you are glad that you married me, the CEO, and not the guy pumping gas!” To this his wife quickly replied, “Actually, what I was thinking was that if I had married him, he’d be a CEO and you’d be pumping gas!” Elaine, thank you from the bottom of my heart for being my best friend, my love, my joy, my partner, and my companion in the journey of life. Anything I have been blessed to achieve has been through your support, encouragement, and partnership. You are a joy to me. Thank you. There are many things I could highlight and review with you today about our society and its engagement on various fronts related to medical and surgical education and that would be a typical focus for this address. I have, however, chosen to leave those important items to our board and business meetings and to the discussions that our excellent program will stimulate during our time together here in Chicago. Let me here say also a special thanks to Karen Deveney and the program committee for their outstanding work on putting the educational feast of these few days together for us. What I would like to do instead with our time together this morning is speak to you from my heart, and I would like to respectfully ask that you open yours to me, if you are willing to trust me with that for the next 90 minutes (just kidding…I wouldn’t listen to myself for that long either). If you are so willing, I would like to speak from
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that foundation and say something that I hope would stimulate us all to reflect together on some issues that I trust are truly of ultimate importance to what we do as surgical educators, and in fact, as human beings. In the format of an educator, I would like to then begin by sharing with you what I hope to demonstrate. First, I want to suggest that as educators, we live in challenging times, and this can easily distract us from what is of greatest importance. Secondly, I would like to suggest that character or virtue is our learners’ greatest need, and is our greatest contribution to their development. Third, I would like to focus briefly on the “how” element, looking at how disciplines and habits can enable us in this effort, both personally and professionally. Finally, I would like to suggest that the core of our learners’ competence, and the core of our own competency as educators, is what we choose to value or ascribe ultimate worth to, and then pursue with discipline. Modern prophets have characterized our contemporary situation well, including as pertains to medical education. Einstein1 said, “Perfection of means and confusion of goals seem…to characterize our age.” Eliot2 made the point that current human endeavor had oriented itself to finding “… systems so perfect that no one will need to be good.” “The system is the solution,” seems to have become a modern mantra, and not just as an advertising slogan for Ma Bell and AT&T. Lewis, commenting on the differences between how historical thinkers and modern ones addressed issues of fundamental importance, pointed out that, “For the wise men of old, the cardinal problem had been how to conform the soul to reality, and the solution had been knowledge, self-discipline, and virtue. For…applied science…the problem is how to subdue reality to the wishes of men; the solution is a technique.”3 Lewis4 further captured the limits of a purely technical approach to societal development when he pointed out that, “You cannot make men good by law, and without good men, you cannot have a good society.” If we look at this mindset as expressed in current medical education, we can see some significant parallels. On the positive side, there is an appropriate focus on outcomes, an increasingly detailed orientation to performance, and an ongoing quest for meaningful metrics that might help us predict performance and outcomes. However, to use Einstein’s phrase, this seems to have facilitated a world very preoccupied with tools, and perhaps distracted or even confused about goals. Let me illustrate briefly. If one looked at the dashboard of an early generation Volkswagen, one would find there is a speedometer, and no other tools oriented toward measurement to occupy the driver’s attention. Conversely, one would find a rather large area of window or interface with the outside world, allowing a direct, rather than metricdictated and indirect, interaction with it. If one compared this to a modern or contemporary Volkswagen dashboard, one would note there are quite a few more measuring tools e4
occupying the driver’s surrounding physical and attentional space, and correspondingly there is considerably less room to directly interface with the surrounding environment through windows and windshield. If we take this a bit further to the cockpit of a modern jetliner, we would find that the measurement systems relaying information about the surrounding world to the pilot have literally taken over the occupant’s space and have in fact necessitated a very limited and arguably superfluous residual window to the visible outside world as those systems have proliferated. Is there perhaps the danger, in such a progression, of distraction by tools that leads to unintentionally dangerous interactions with the outside world? (picture of driver with cell phone)… I think the answer is yes. So what I mean to suggest by this perhaps crude example is that while tools and metrics can offer us increasing information about, and potential for control over our environment, allowing increasing speed, comfort, efficiency, and safety, they often become cognitively dominant for us in doing so and have the potential thereby to distract us from the most important aspects of our interaction with the world around us. As an example of such, the crash of Air France Flight 447 into the Atlantic Ocean in 2009 was ultimately attributed to the inability of the flight crew to cognitively override confusing data presented by the plane’s control systems when the autopilot was disabled by ice build up on the plane’s Pitot tubes (used for airspeed measurement). A 30,000 ft fall into the ocean over 3 minutes was the result, with the haunting black box exclamation from one of the pilots shortly before impact, “We are going to crash, this is unbelievable!” Now if I were to bring this theme home to our world as medical and surgical educators, I would highlight some of the increasingly sophisticated measurement strategies and related tools that have evolved in the past decade. These would of course include the core competencies as illustrated in the Accreditation Council for Graduate Medical Education and CanMEDS iterations, and the more recent milestones project. I want to emphasize that I believe these represent outstanding efforts by very thoughtful colleagues who are clearly working to help us improve the quality of our learner assessments and our training programs. At the same time, when one adds up the elements of measurement and assessment entailed in these efforts, alongside contemporary financial and curricular mandates, one ends up with a daunting array of pressures that, while all best-intended, make the jobs of the people in this room seem overwhelming. In prior work at SIU, ongoing compliance with the first iteration of the competencies was calculated to have profound effects on resident workload, recurring faculty workload, and especially the workload of program coordinator support staff. Accordingly, for the older members of the audience, the current status of medical education may bring back memories of a piece of popular culture prophecy from 1970, Alvin Toffler’s Future Shock. In that work,
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Toffler5 defined the condition his title described as a psychological state of individuals and entire societies as a perception of “too much change in too short a period of time.” For many in the audience today, Toffler’s projections regarding the pace of change in graduate medical education ring strikingly true. Going back to our automobile and cockpit analogy, the question I would like to pose for our consideration this morning is how might our current milieu, as it pertains to graduate medical education in the United States, while providing us with a wealth of detailed information regarding our learners and their progression, distract us from more important and fundamental tasks? Perhaps more importantly, what might those tasks be, and how might we show care to address them in the midst of our evolving and potentially distracting educational ambiance? To harken back to the insights of the previously quoted modern prophets, how do we remember the goals amidst the proliferation of tools or means? How do we produce a product recognized as “good” while the systems within which we must function become increasingly complex? How do we not end up joining the Flight 447 copilots in offering our statements of disbelief as the challenges of current graduate medical education (GME) threatens to stumble under its own weight, while we carefully mind more data points than ever in our attempt to keep the ship on the right course? In answer to the question of priorities, John Tarpley shared with this group in his 2008 presidential address that according to American Association of Medical Colleges Chief Medical Officers, the greatest challenge they faced was “increasing the professional behavior of our faculty.” In his 2007 exit interview published in the Accreditation Council for Graduate Medical Education Bulletin, David Leach, referring to Parker Palmer’s influence, commented that “…we teach who we are.” He further elaborated that “…although (the residents) journey is full of external drama, it actually proceeds from the inside out and is about character development” (emphasis added). “Residents model behaviors and values; they especially value faculty who ‘live divided no more,’ i.e., whose external behavior is always aligned with deeply held inner truths.” To further highlight that these issues of character on the part of educators, and character development on the part of our learners, is in fact of very current importance to our thought leaders, I would highlight Carlos Pellegrini’s Presidential Address from last fall’s American College of Surgeons Clinical Congress, in which he outlined that surgeons of the future will need a moral compass to navigate changes in the profession. Perhaps even more poignantly, in a book recommended to me by Reed Williams, and which some of you in the audience have read, Donald Schon’s “Educating the Reflective Practitioner,” Schon highlights the implications of our professional failures to address these issues of values and ethic. He states, “When professionals
fail to recognize or respond to value conflicts, when they violate their own ethical standards, falls short of self-created expectations of expert performance, or seem blind to public problems they have helped create, they are increasingly subject to expressions of disapproval and dissatisfaction… public, radical, and professional critics voice a common complaint: the most important areas of professional practice now lie beyond the conventional boundaries of professional competence,” (emphasis added).”6 I need to digress for a moment here and acknowledge that much of what we know of character is developed long before we match a resident, or for that matter are hired ourselves as faculty members. I am reminded of a biannual performance review faculty meeting I chaired some years ago at a noble and now since twice renamed institution in the South. In that meeting, we were struggling greatly with our collective assessment of a senior resident who, in a scenario perhaps too familiar to many of you in the audience, had transferred into our program after preliminary training elsewhere with good reviews, only to prove to have some challenges with his work ethic, and in particular, as a senior resident with how he delegated or “dumped” on his colleagues. After debating (again) for some minutes on the challenges, the largely ineffectual results of counseling and “chair time” with myself as program director, and our collective ineffectiveness in facilitating a change in this trainee’s performance, a faculty member piped up from the back of the room with one of those pithy pieces of wisdom that I need John Tarpley to help me say properly. I quote: “Listen y’all, this boy’s momma screwed up and you ain’t never goin’ to make him right!” This was perhaps the most profound statement I have heard at a faculty meeting in 25 years! As further reinforcement for the veracity of this challenge for all of us as adult educators, I would highlight work done by my colleagues at SIU. In a 30-year review of resident performance problems, Williams showed that while we identified 82% of problems in the first year of training, and 94% by the third year, 88% of residents identified with problems in the course of their training had persistent problems at their completion of training. Problems that were either solely or in part related to professionalism issues were the most prevalent in that analysis.7 Having recognized this challenge of trying to address character development in adult learners as a real one, I would submit that we cannot afford as a profession, and as a generation of educators, to leave unaddressed Schon’s “most important areas of professional practice” simply because they seem to lie beyond our current “boundaries of professional competence.” What we need to do is not acquiesce under the weight of our weaknesses and failures; rather, we need to look deeper into our nature and its potential for reformation, for renovation, in order to chart our course. I would like to pursue this in 2 phases. First, I would like to examine some of the features of our human nature that
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we all recognize experientially, i.e., that we can’t not know to be true. I will highlight here a superficial summation of some of the work of a recently deceased Professor of Philosophy from the University of Southern California whose work has had a profound influence on my thinking in my midlife years. Willard8 points out that all of us make choices from an inner world of thoughts, emotions, and will that has been variously described through history as our heart, mind, spirit, thought-life, consciousness, etc. For the purposes of our discussion today as reflected in my title, I will use the word “heart” for this element of our nature, as despite its anachronistic anatomical limitations for us as moderns, it keeps me from thinking of this delineation of our fundamental self and identity as a purely materialistic process of neuronal processing. I would hear interject, and I hope very humbly, that if there are any rugged materialists in the audience, who might define our “heart” or value issues as purely neuromechanical byproducts of the chemistry of our brains, I myself cannot embrace that mindset for a number of reasons. Not the least of these is that with our contemporary understanding of DNA, a purely materialistic interpretation of reality would require that I believe matter can produce information, and no empiricist has ever seen that. But I digress and don’t want to sound polemical beyond my credibility. The point of this issue of our “heart” is that we all see and interpret reality from this inner world. Furthermore, our responses to our environment from this inner realm, including and especially our creative choices of will, are amongst the most important things about us—our character. After considering these features of our nature, I would like to examine disciplines and habits, and how they can help us address the daunting challenge of character formation and reformation, even in our relatively ossified status as adult learners. It is important before I go on to spend a moment reflecting on some challenges we have in this era regarding how to process our handling of this issue of values, character, and the related theme of truth. In our postmodern times, we have largely adopted in the west a concept of truth, at least as practiced in the highest realms of academia and our sociopolitical structures, that views truth as at best a relative term. We like to think we’ve escaped this in the sciences, but a quick review of the medical literature and the position and especially advocacy statements of our esteemed professional societies reveals much that is born of self-service rather than a rigorous standard of evidence and logic. The sound bite thinking and “spin” rhetoric that categorizes some of our most important collective social dialogues, such as political campaigns and the reporting of our news media, is a reflection of this. Secondly, thinking ourselves productive because we are busy, large segments of our society, including perhaps much of our profession, have largely abandoned reflective disciplines, despite the fact that these have been some of the most fundamental activities for geniuses and other e6
productive humans over the course of our history. In addition, we have, in the west, especially in Europe and increasingly in the United States, embraced secularism as a key feature of our worldview. While I would perhaps be abusing my privilege of the podium by turning this discussion into one that would be seen as “religious” in orientation, I do want to highlight that this movement in thought has profound implications for issues such as hope and accountability, to which I shall return in a few minutes when we consider the theme of character reformation as illustrated in addiction science. Nietzsche’s idea that he had killed God by rendering him useless in his philosophy, and that the moral “ubermensch” or “superman” was someone who did as he pleased out of moral independence was not just philosophic philandering, but provided an intellectual foundation for the actions of twentieth century pogroms and genocides and informed the self-described mindsets of serial killers such as Ted Bundy, along with a host of less infamous followers of self-ordained moral authority. Finally, our consumerism in the west has become our buffer against serious reflection on these challenges. As Gary Dunnington’s son Kent has suggested in a powerful book on addiction and what it teaches us about modern times, our spending of money, and I might add including on health care items that do not add value to our patients’ lives, has become our means of “…distracting ourselves from the frightening possibility that we really don’t know what is worthwhile.”9 To that I say a personal, “ouch,” and thank you, Kent. Please bear with me here for a moment. I realize that’s a lot to cover in a talk on GME, and I am no philosophic expert or trained cultural critic. What I am trying to suggest is we must not lose the ability to reflect meaningfully on our own liabilities and blind spots in the era in which we live if we are to prepare our learners to understand what is important and pursue it with diligence. David Brooks talked about our collective societal failure to accomplish this for the best and brightest of our next generation in a New York Times piece from May 24, 2012, and referenced by Keller10 in his excellent book on work and its meaning, “Every Good Endeavor.” Brooks describes a survey a Stanford professor did of students and recent graduates to evaluate why so many top graduates of upper academic tier universities were going into jobs in finance and consulting. It was found that students chose jobs in one of 3 categories: financial reward, service to society, or the “cool factor,” meaning something like a job at Google. What was disturbing was the general lack of an ethic that allowed work to be interpreted as character founded and of meaning based on one’s gifts and sense of calling to serve the common good. Brooks outlines that a large segment of the “community service” subset appeared to be comprised of individuals who chose the field not for its relevance to their sense of giftedness or personal purpose, but because, “Community service has become a patch for morality.
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Many people today have not been given vocabularies to talk about what virtue is, what character consists of, and in which way excellence lies, so they just talk about community service.” One wonders parenthetically if some of our current medical students are looking for a parallel sense of meaning or purpose for their labors in a vocabulary vacuum such as Brooks suggests, as evidenced by the surging interest in global health. He continues, “…around what ultimate purpose should your life revolve? Are you capable of heroic self-sacrifice, or is life just a series of achievement hoops? … You can devote your life to community service and be a total schmuck. You can spend your life on Wall Street and be a hero. Understanding heroism and schmuckdom requires fewer Excel spreadsheets, more Dostoyevsky and the Book of Job.” I would join Brooks in suggesting that we will not resolve the fundamental needs of our resident learners by continuing to polish and refine our GME spreadsheets but by focusing on their unique gifts and how they might best be used to make the world a place of more common healing, grace and peace. So back to our inner world—do we really think (a la the critical comment I shared earlier that my Southern colleague made in regard to my former resident’s maternal influences) that this inner dimension of our personhood can be reformed? I would concur with Willard that virtually all influential figures in history have felt it can, for better or for worse, even at a societal level. Witness Nazi Germany, Cambodia, the rise to independence of India, and the Solidarity movement in Poland, to name a few. Or witness William Wilberforce’s lifelong effort to bring down the slave trade in Great Britain in the late 18th and early 19th centuries, or the civil rights’ movement in our own country. In each of these instances, individuals of deeply held internal convictions, constructive or destructive, influenced the course of whole societies and their collective hearts or soul. The concept that this inner world can be changed lies behind all meaningful events to improve our human situation, both public and private, again as Willard has pointed out. I will give here a brief example from history. My outline here will be to follow what Steve Sample, President of the University of Southern California, has recommended. In his book The Contrarian’s Guide to Leadership, Sample suggests you shouldn’t read things that aren’t at least 400 years old, as that is a reasonable test of a work’s enduring value.11 This is attractive in that it shortens one’s reading list considerably. I will apply this principle in several of my following developments. First, in Jesus’ Sermon on the Mount, he highlights that it is a rightly ordered inner world that is essential to right outward behaviors. For example, he highlights that to pretend to be outwardly what we are not inwardly is highly destructive and dangerous, that right living has a preservative and illuminative impact on society, and that accordingly, we must manage our inner motives and thoughts and not just our outward behaviors for
appearance’ sake. Hence, our speech should not be manipulative but be an accurate presentation of our position, retaliation replaced by concern for one’s opponent and service to them can be transformational, and philanthropy, if to be about others, should be private and not public, and so forth. Without question, these ideas contrasted greatly with prevailing norms in the Greco-Roman world and profoundly affected the subsequent course of western and world history. If we were to extrapolate this underlying principle to the realm of GME, we would distinguish between appearance management mode and motive mode. If we are focused only on the former, we might ask whether a resident completes their records and follows handoff protocol as a competency and compliance measure and check the according box on their evaluation form. In the latter mode, however, our concern would be whether the resident fundamentally desired others to have the information they needed to optimally care for the patient. If we can address the motives, the behaviors will follow. Let me parenthetically state here that one of the things the milestones are working to helping us articulate is indeed focused at this “heart” or motive level of assessment. For example, on the professionalism competency and Care for Diseases and Conditions Practice Domain, the resident must demonstrate qualities such as honesty at level 1, empathy at level 2, integrity at level 3, and self-sacrifice for the good of others at level 4 (page 8 f Milestones). While measurement can be a challenge, this type of defining of qualities that must underlie behavioral competence is, in line with the arguments I am making, of real potential help to us as mentors and teachers. I would now like to move on to how this type of teaching, or character reformation, might be accomplished. Willard suggests that renovation of our inner world requires a vision of our goal, the intention to pursue it, and the means of pursuing that goal, which involves behavioral disciplines. The integration of our thoughts, emotions, and will, and of our physical body in the spectrum of these domains of vision, intention, and means, touches on all aspects of who we are as humans. I would submit that our learners can achieve the vision element through effective role modeling, which then invites their intentional pursuit of the character or quality they see in us as educators, and the behavioral discipline aspect through our coaching efforts, giving them practices and actions to deliberatively pursue. This latter element is much as we might advise them to do for technical skills training. Kent Dunnington in his Addiction and Virtue, to which I have previously referred, reflecting on Aristotle, offers the following: “(mental assent to an idea that something is good or right) must be translated in to ‘heart knowledge’ (emphasis added) as well. The student of right action must come to embrace in an effective way the actions that he has come to believer are right. And this takes time and practice, which is to say that this takes habituation,” (emphasis added).9 One of the duties of
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the educator, accordingly, is to demonstrate concrete behaviors that our learners can adapt in their own disciplined pursuit of competence, and which allow them to translate their will and intention into behaviors that, over time, habituate their intellectual and volitional efforts into “heart knowledge,” allowing Aristotle’s translation to occur. As an example of how this might be done, let me briefly describe a project I did while at the Medical College of Georgia and have since shared with audiences in several other academic centers, all of whom seemed to find it meaningful. In an effort to operationalize the competencies, I sat down with our residents in a sort of “focus group” and asked them who on the faculty best embodied each of the 6 core competencies as they (the residents themselves) defined them. I then went, using this appreciative inquiry approach, to each of the identified faculty and interviewed them regarding what personal disciplines they followed that they felt had helped them achieve a high level of performance in that particular competency domain. So, for example, the faculty member identified as demonstrating the best practice-based learning skills identified his experiences of being humbled by his shortcomings in patient care as a resident and learned to respond to those situations by dutiful study to allow himself to become an expert on the topic in which his shortcoming had been made apparent. He then would seek an opportunity to teach students or others on the topic as a way of sharing what he’d learned and testing his depth of understanding. In those areas of expertise he so leveraged, he subsequently sought to maintain a current body of knowledge through continued focus on any new information on the topic that the literature would offer over time. His “failures” thus became, through a disciplined approach to what we would call practice-based learning, areas in which he became adept and, in fact, became a resource to his learners and colleagues. The importance of such disciplines and habits in our behavior has been summarized recently by Duhigg12 in his book, The Power of Habit. I recently read this work after encouragement by my dean, Kevin Dorsey, as we discussed how to train our students in professionalism. Duhigg summarizes that habits dictate 40% of our behaviors, can be mapped neurophysiologically, and can lead to selfdestructive behaviors such as addiction. Studies at Massachusetts Institute of Technology on rats demonstrate that habit development involves neurophysiological “chunking” at the level of the basal ganglia, which in a fashion parallel to our understanding of skills learning theory, or perhaps even the cortical plasticity work that Dimitri Anastakis has presented at Surgical Education Week in the past, frees up cognitive space from being immobilized by endless behavioral choices. This is critical not only to how we brush our teeth or park our car but to our behaviors that would be seen as representative of our fundamental values and character. Kent Dunnington, in this case amplifying on e8
Aquinas, outlines that “A life that is perpetually involved in dealing with moral crises of action will inevitably be a failure. The problem with such crises, for Aquinas, is not that they are irresolvable, but rather that they tax the moral agent. The goal of moral training is the formation of moral habits, because habit names the possibility of acting well without the exertion that is required of deliberative practical reasoning,” (emphasis added).9 In Duhigg’s analysis, there is a “habit loop” that involves a cue or stimulus, a routine that is learned and constitutes the behavioral element, and a reward for this behavior. The key to change in his analysis involves substituting behaviors or routines in response to the stimulus that still are reinforced by the reward. In analysis of individuals and groups who have successfully pursued change, several important lessons have been noted. First, there needs to be meaningful belief that change can occur. Secondly, communities make change believable. Note here our earlier comments on the hope and accountability, and the use of Alcoholic Anonymous’ principles of a “Higher Power” and sponsors. Third, willpower is self-reinforcing, and therefore has a developmental or compounding aspect, the corollary of which is it can be fatigued. Finally, keystone habits can have contagious effects, as is seen with contagious culture change in organizations, or I might add in my own observations, successful remediation efforts with residents —one small “win” often brings in its wake a self-reinforcing capability to constructively engage in other disciplined behavior with compounding success. In this latter regard, Duhigg shares some wonderful stories about experiments with willpower. For example, many of you have seen humorous videos of the studies done on small children asking them to try to avoid eating marshmallows with the promise that if they did so discipline their oral intake for the defined time of the study, they would be given more marshmallows at the end. Those children, who at a young age could accomplish that brief exercise in delayed gratification, were found on delayed follow-up to have an average Scholastic Aptitude Test score 210 points higher than the children who couldn’t wait (more predictive than intelligence quotient) and were more popular and less likely to use drugs as teenagers. Conversely, in an adult study where subjects were asked to avoid eating radishes vs warm chocolate chip cookies (a poor pre-lunch illustration, I understand), and were subsequently asked to work on a puzzle that was not solvable (unbeknownst to the subjects), the cookie-resistors worked 60% less long on the puzzle, suggesting they expended more of their “willpower bank” resisting the more inviting food option. These studies, along with the keystone habit concept, offer an interesting model of behavioral conditioning and fatigue that goes well beyond our calculations of hours worked and may help explain professional and moral failures by normally effective practitioners in ways that go beyond simple sleep cycle analyses.
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So what kind of disciplines might we then suggest to our trainees, or better yet model for them, which will instill in them a vision for what they might become at the level of their inner worlds, which will invite their personal commitment to invest in that goal intentionally, and which will practically equip them, by our earnest if obviously imperfect examples, with behavioral disciplines that they might imitate to begin a process of habituation that equips them with those skills and behaviors as relatively automatic responses? Again, what I am proposing is not dissimilar to what we would preach to them in technical skill development and the deliberate practice we espouse to the end of their development in that area. What it will require is a different level of intimacy and transparency with them regarding our own hearts, but if David Leach was right about what they want from us as teachers, the results could be refreshing, if not revolutionary. Some of the personal disciplines I have personally found most helpful in these regards, and which when I do it well (which is inconsistently at best), are as much in action at M&M’s or over a pancreatic resection as they are over a cup of coffee at a semiannual “mentoring meeting,” include the following: open gratitude, acknowledgment of failure, purposeful humility (which often equates to sound judgment), focus on the needs of others, acknowledgment of false appearances when I have wrongly facilitated them (e.g., “the literature says…” when I am only aware of one article and don’t know the reference), solitude (which can help allow a space to listen and become sensitive in all the above areas), and reflective reading that crossexamines my self-assured and self-centered behaviors (here I would say the 400-year rule really applies well—it’s easier to see your flaws when you tolerate the perspective of an age other than your own). Finally, and again I owe my thought here to Dallas Willard, once you get started on this, there is a potentially endless curriculum in which one can engage. An acquaintance of Willard’s tells the story of watching him finish a scholarly philosophic talk at the end of which a relative novice in the audience stood up and rather naively critiqued Willard’s presentation. Willard thanked him for his comments and offered no rebuttal. The friend approached Dr. Willard after the session and asked why he hadn’t totally refuted and embarrassed the brash and uniformed critic in the audience. Willard’s response was that he had become convinced he needed to work on the discipline of not always having the last word, and felt he had been provided a good opportunity to practice just that. What our trainees wouldn’t give for some surgical educators with that spirit, myself included! Perhaps that will be a topic for a new faculty development session that I could certainly benefit from personally! Well my friends, you have listened well, and I thank you for that. In review (and I remember here that I am speaking to a group of wonderful educators, including many of my own mentors, so forgive my pedagogy), I have suggested that as educators, we live in challenging times. There is a
danger inherent in our era that we will be distracted from what is most important, and I have further outlined that what our learners need most from us is the demonstration of character and virtue lived out from rightly ordered inner worlds in the context of our daily professional duties. I have suggested that what ancient thinkers and modern science have taught us about habits as engendered right actions can help us in these regards. I have also argued that personal disciplines “of the heart” can both help us grow in an ongoing, individualized, and lifelong fashion and can allow us to demonstrate for our students the means by which they may pursue the progressive ordering of their inner worlds as necessary foci of renovation if they are to be effective caregivers in the challenging profession which we share. I have argued that we have special liabilities in these efforts linked to our contemporary societal worldview and need to be far more self-critical in these regards if we are to really contribute as luminaries or reflectors of truth, rather than educators “du jour.” I now offer one final thought. I suggest to you that what our inner world reflects, and therefore becomes that alone which we can truly model and teach someone else, is what we ourselves supremely value, or if you will, what we “worth-ship.” I recently heard the true story relayed of a man who became somewhat unexpectedly and lavishly wealthy. He hired a life planner to help him decide what to do with his precocious prosperity. After spending a considerable amount of time with the man and his spouse, the life-planning coach walked to the white board and drew a box on it. He said to the man and his wife something like this: “I have learned much of your life, your interests, your goals, and your passions. I am prepared to help you decide how to pursue those things with the resources you have. But there is one thing, the most important thing, which you have not yet told me. I need to know what of all that you value most, because that determines everything. Tell me what to put in the box.” Colleagues and members of the Association of Program Directors in Surgery, my own mentors and friends, and yes, the question I ask of my own heart, what is it that our generation of surgical educators wants to put in the box? What is our highest value? Is it our appetites for fulfillment, influence, or reputation? Could it be our curriculum vitae, our retirement plan, the number of cases we’ve done, or the profitability of our sections, divisions, or departments? Could it truly be our service to others and especially our trainees, fulfilling our societal mission to “support program directors in optimizing the training of tomorrow’s surgeons?” Might it be a relationship with our Maker that profoundly and positively impacts our every relationship on earth? I cannot tell you what answer you may offer to that question, as our nature as humans dictates that we must each answer in our own hearts. I do close, however, by encouraging us individually and collectively to answer it, and to live out our answer with all the integrity we can muster, and with much humility for our failings. I would strongly encourage us as we contemplate this to evaluate our answers by 2 important criteria: are our answers timeless, and are they
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relational? I would suggest that answers we offer that fail in those regards will lead to disappointing results, as they are likely to be dictated too easily by convenience and our propensity to the default of self-interest. The answer we give to this question individually and collectively defines vision, orients intention, and provides a template for disciplined behavior through which we can bring our outer world into an integrated expression of our inner reality. For our learners, leading lives that exemplify this, and which demonstrate those disciplines as expressions of a rightly ordered inner world, is the greatest contribution we can offer them. This is a life of integrity. This is the call for the educator of our time. From the bottom of my heart, I thank you, my colleagues and friends, for the privilege of serving as your president and for the privilege of your podium. Blessings on each of you, and on this fine organization, for years to come.
3. Lewis CS. Illustrations of the Tao.The Abolition of
Man. New York: Collier; 1955. 4. Lewis CS. Mere Christianity. New York: MacMillan;
1952. 5. Toffler Alvin. Future Shock.
New York: Random
House; 1970. 6. Schon Donald. Educating the Reflective Practitioner.
San Francisco: Jossey-Bass; 1987. 7. Williams RG, Roberts NK, Schwind CJ, Dunnington
GL. The nature of general surgery resident performance problems. Surgery. 2009;145(6):651-658. 8. Willard Dallas. Renovation of the Heart.
Colorado
Springs, CO: NavPress; 2002. 9. Dunnington Kent. Addiction and Virtue. Intervarsity
Press; 2011.
REFERENCES
10. Keller Timothy. Every Good Endeavor.
1. Einstein Albert. The common language of science.
Broadcast for Science. Conference; September 28, 1941. 2. Eliot TS. Choruses from the rock. In: Collected Poems
1909-1962. New York: Houghton Mifflin Harcourt; 1963.
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USA: Penguin
Group; 2012. 11. Sample Steven B. The Contrarian’s Guide to Leadership.
San Francisco: Jossey-Bass; 2002. 12. Duhigg Charles. The Power of Habit.
New York:
Random House; 2012.
Journal of Surgical Education Volume 71/Number 6 November/December 2014