Henry Goldstein: Failing Forwards at DFTB17


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At the time we began planning #DFTB17, I was eager to speak on the concept of Failure. I’d just failed yet another college examination and was keen to describe my personal experiences. But along the way, I discovered that failure is for everyone. Here’s what I had to say:

Take home points:

  1. Failure is for everyone.
  2. Embrace failure; you don’t need to be a Greek God or superhero to overcome failure.
  3. Use failure; to turn pro.
  4. Seek out failure; it’s part of a growth mindset.
  5. Failure is just another opportunity to grow.

If you have drawn breath, you have failed.

I’m speaking here at DFTB17 because I have failed. Repeatedly.

I have objectively failed at university, medical school and several college-level exams. I have failed in the workplace. I have failed to perform to my potential in sports. I have failed to listen in relationships. I have failed to be present for my children. I have failed to care for my own well-being and health.

But, failure is essential on the path to mastery.

Although I’m not a master of anything yet, my brushes with failure have lead me to think and read about, the science and art of what it takes to become a master, understanding the integral role that failure plays in the process. In talking about failure, I will not hark to the manufactured significance of famed athletes or teams, nor the red-misted stir of a battle cry, nor a prolonged myopic and cringeworthy dissection of my own many failures. Instead, with these kind of narratives present in our conscious, I am going to examine failure.

Dunning & Kruger, in their classic description of a cognitive illusory bias, postulate that in the mastery of anything, we all fail, repeatedly. Firstly, we rapidly ascend Mount Stupid, failing to recognise our own incompetence. Next, we plunge into the valley of despair, failing to know enough. Then, we fail and fumble along the path to mastery. At each step, we fail to accurately assess our competence.

Kruger J, Dunning D. Unskilled and unaware of it: how difficulties in recognizing one’s own incompetence lead to inflated self-assessments. J Pers Soc Psychol. 1999 Dec;77(6):1121-34.

As Ross Fisher noted in his talk, the popularly recognised Dunning-Kruger curve is not seen in this paper; instead, it is derived from Saturday Morning Breakfast Cereal, hence:

The real Dunning-Kruger curve

We all fall. Failing, or “the fall” is a universal part of the human experience. It is central to our existence, across time and culture. It is an inevitable waypoint on the path to mastery. In fact, a big data project based at the University of Adelaide sought to analyse the emotional arc of the protagonist throughout western literature, using a Project Gutenberg, Artificial intelligence and machine learning. The researchers found that of the nearly 2000 works, only six trajectories occurred; one of the most popular being the “Man in hole” arc, also known as “Fall-rise”. It is the fall rise arc that starkly mirrors the Dunning-Kruger curve inherent to mastery.

Reagan A, Mitchell L, Kiley D, et al. The emotional arcs of stories are dominated by six basic shapes EPJ Data Sci., 5 1 (2016) 31.

In some frame, failure is present in your life. I’m going to talk now about three things to do when failure presents itself;

Embrace Failure:

First we must embrace failure. The Greeks described the fall as a key component to any heroes’ tale; they called it katabasis (κατάβασις). Although the term can be used generally to describe “going down”, it is specifically used described a journey to the underworld. Odysseus, Hercules and Aeneas all visit Hades in their journeys. But, in addition to a trip to their own private manifestation of hell, one of the key features of katabasis is the acquisition of a life-altering skill or knowledge.

The heroes, on their katabatic journey downward will almost always be accompanied by a companion. Choose a guide in the form of mentor, peer or sidekick; they are invaluable as the road plummets. Although not distinctly the protagonist, the arcs of Hermione & Ron, Mister Spock and Gandalf all include their own failure and subsequent mastery. When you embrace failure, take a guide, lest you become lost. We all need food, shelter, warmth and love. But, like all myth and legend, the failure and rise of heroes only persists because they mirror our own fears and aspirations.

Let me be clear; embracing and overcoming your failures doesn’t make you a hero. Nor do you need to be some kind of superhuman to embrace failure.

There’s an Edgar Allan Poe story called “A Descent into the Maelstrom,” about a fisherman whose boat is sucked into an enormous whirlpool.

Down he spins into the roaring vortex, certain he’s going to die. Then something strange happens.

In his delirium, he relaxes and, to amuse himself, makes a game out of studying how the whirlpool works. As other boats are been drawn in destroyed, and he notices that the pieces of junk and debris whipping by behave in different ways depending on their shape. The vast majority hurtle rapidly downward, but cylindrical objects such as barrels aren’t swallowed up as easily.The barrels linger up near the top of the vortex, close to the surface.

Consequently, the fisherman lashes himself to his own water cask and leaps overboard. It works. The boat continues whirling down to its doom, but he doesn’t. He sinks no further. Eventually the whirlpool subsides he’s back on the surface, the sky clear, the winds dying down, and a full moon was setting radiantly in the west. He’s saved himself. He embraces failure and he survives. But Poe’s sailor does more than embracing failure; he uses it.

Edgar Allan Poe. A Descent Into The Maelstrom (1841).

Use Failure:

I would speculate that most of us are embarrassed about the universal failures inherent to seeking mastery. It shames us. We reframe it, blot it from our memories and personal narratives. What is more challenging, is to use failure. Ruthless self examination, cognitive honesty, and self-awareness are processes with their roots deep within failure.

To look at yourself in the mirror and unflinchingly declare “This is my weakness! I have failed. This experience is part of me.”

Do not flee; you will want to. Do not kid yourself; it’s easy to do so, and others may help.

Find some kind, honest, frank, support, and lean on them. And when you do this, identify that it’s not about you.

All mastery is about the process. Your ego must be subdued, in order to analyse your failings dispassionately and with distance; as if you were a colleague or objective observer. And then, with kindness and humility, set upon a course of improvement. In short, We Turn Pro.

Turning Pro:

The War of Art is a punchy, confronting, book by the American author and Screenwriter Steven Pressfield.

Pressfield S. The War of Art. Black Irish Entertainment. 2011.

He wrote it because he was stuck and failing, repeatedly. In fewer than two hundred sledgehammer pages, he describes repeated failure, and the path towards “turning pro”. The book is pitched primarily at creative folk, but for those of us called to the vocation of medicine, it is filled with gems.

First, he says, we must overcome resistance. Resistance is any of the squillion insidious obstructions that claw at us, that hold us down, tell us we are too small, stupid, weak or inferior. Resistance diverts us into a world of past glories, hedonic exhilaration and far away from doing what we know we must do.

To overcome resistance, is to turn pro.

And really, that’s all there is to it.

Turning pro is about showing up, and creating the conditions to focus deeply and to be present in our work, but more on that soon.

Pressfield ruthlessly compares and contrasts the amateur and the professional.

On one hand, the amateur over identifies with their calling, yet is paralysed by ego. They cannot act nor produce. They are fearful of the fall. The amateur focuses almost exclusively on performances, achievement and prizes.

By comparison, the professional is like a hunter; they’re not in it for the prize; they are in it for the hunt. A professional gets their hands dirty. They love their craft so deeply, they need to establish professional distance. And that’s why the professional plays for keeps. The professional focuses on technique, and the outcome takes care of itself. By toiling beside the front door of technique, the professional leaves room for genius to enter by the back.

The professional consistently establishes and maintains the conditions from which mastery can originate.

Phases of professional development:

Pressfield’s views are similarly ratified by some of the scientific literature. In 2003, Ronnestad & Skovholt described the “Phases of professional development”, neatly breaking down the entire career trajectory into six phases. Although the study was about therapists and counsellors, the similarities between their professional evolution and our own are stark.

Rønnestad M & Skovholt T. The Journey of the Counsellor and Therapist: Research Findings and Perspectives on Professional Development. Journal of Career Development. 2003. 30(1)pp5-44.

Having seen the guest list, I’m certain that there’s at least one member from every group here today. So how does this evolution occur?

Firstly, Lay people acquire some medical knowledge, they care, they have health discussions, and to an extent, some understanding of science. But their boundaries are blurred and inquiry is often focussed more narrowly, either in time or scope.

The Beginning Student is met with volumes upon volumes of theory, and no practical experience. They are often disarmed by the tension between newly discovered theoretical knowledge and disempowered because they reflect on the lack of utility of their former “lay person” approach.

The Advanced Student has absorbed a large amount of knowledge, which still outstrips their experience. Consequently, their approach to care is typically rigid, with a dash of frustration with the inevitable discrepancy between patient and theory. My experience as an advanced student found me waving proudly from the top of Mount Stupid; perhaps you’re the same.

Novice Professionals – essentially specialty trainees – are developing a sense of professional self. As supervision is less intense, for perhaps the first time in their careers, novice professionals are at risk of making a decision, and for some this is scary, particularly as the complexity of cases increases. Novice professionals voraciously shed and add both concepts and behaviours through phases described as confirmation, disillusionment and exploration.

The Expert Professional phase of career development involves integration of core beliefs and values into one’s style of practice. I’ve heard this phase of professional development compared to an expert cricketer; the batsman who has all the shots, knows when to use them and when to put them away. Expert professionals also develop a profound acceptance of the uncertainty inherent to clinical practice, and are clearer in their boundaries. Interestingly, Experts have often strongly internalised their early mentors, whom have continuing influence over their style of practice.

Senior Professionals are in the last phase of their career. Many of our field’s senior clinicians approaching retirement have been integral to a golden age of Paediatric medicine, especially for those among us with 40 years experience. This phase of development classically involves legacy, satisfaction, wisdom and just being.

Establishing the Conditions for Excellence:

Returning to Novices professionals; one of the core habits the imitation of seniors. I’d speculate that most of this is not entirely conscious, but on occasion, when we novices see something that resonates, we integrate it into our developing practice.

I know this worked for me and my college exams. In preparation for re-sitting, I was encouraged first by my partner, and then by a senior colleague, to buy some expensive leather shoes, half a size too small, and wear them to work every single day. Call them your consultant shoes, they said.

The next step, then, was to find a professional outfit, colloquially known as an exam suit, but for me, it became a catalyst for psychological transformation.

The advice was explicit; Step 1, get shoes. Step 2, get a new suit. First wear the pants most days, then a tie (every day), and finally, wear the jacket. every day, for months in advance of the examination.

So, every day I worked I dressed like this. Suit & tie. There were no exceptions for weekends or evenings.

As predicted, after some initial surprise that I’d shed my cartoon character scrub tops & bright purple chinos, I found people responding differently to me. With wearing a suit came a mindset of being calm, predictable, reliable, humble, organised, communicative and mature.

As you can imagine after a week or two, my feet were aching, blistering and I had limped to more than a handful of MET calls. But, I found my responses more considered, I found myself as more thorough, rational and systematic than I’d previously thought possible. None of this was actual study, of course, simply cultivating a mindset – creating the conditions – from which to establish the attributes of professionalism and mastery.

And every time my feet hurt, I was reminded that the conditions for mastery were right. By the time I was due to be examined, I had worn in my shoes and my suit had become my workwear, complete with mindset. I was “showing up”, I was beginning to turn pro, and, imitation of experts was progressing me along the path.

And I think this begins to underpin some hallmarks of professionalism;

  • Having a routine
  • Establishing cognitive processes
  • Utilising fundamental theory at a practical level
  • Cultivating habits that establish the conditions for excellence

Of course, I’m under no illusion that I’m anywhere other than at the very beginning.

Turning – and staying pro – is what we see in the excellent clinicians around us. Master clinicians whom use their failures to grow an expert, evolving, broad, humble and comprehensive understanding of what it is to master the craft of medicine.

Post Traumatic Growth:

Mirroring Katabasis is the recognition that with struggle and trauma may come growth. Both health and lay-folk have a pretty robust understanding of Post-traumatic stress disorder; what is less well understood is the concept of post-traumatic growth (PTG).

The pioneers in this field, Tedeschi and Calhoun have, over the last twenty years identified some of the conditions that make Post-traumatic growth more likely. I’m going to briefly mention two;

The first is Rumination & Cognitive engagement. Rumination tends to have negative connotations, but in this context, Tedeschi and Calhoun are using the more traditional definition “To turn over in the mind”. They identified that the degree of PTG is related to rumination about elements related to the event.

This rumination is not the same as the intrusive, unwanted thoughts inherent to PTSD; instead, these are a reflective, deliberative, cognitively engaged process.

In short, thinking about – really examining – your failures is an evidence-based way to grow from them.

The other fascinating component of Post-traumatic growth is the sociocultural context; most specifically, how the people around us view, discuss and conceptualise trauma.

The best evidence is that your potential for post-traumatic growth is heavily influenced by how others respond to your experience, how much they agree and whether the group has a general model for post-traumatic growth.

This means that if your experience of talking about failure is to be told – either implicitly or explicitly –  to “bottle it”, you won’t grow. This can be problematic in medicine to say the least, and if we think about Dunning-Kruger, may see us get stuck at the curve’s nadir.

Conversely, when we share our experiences, consider and reflect upon our failures, we use them to grow.

Seek Failure:

Dr Carol Dweck has pioneered research in understanding the mind since the early 70s. She developed the term “learned helplessness”, and undertook a slew of studies investigating and measuring why and how we think the way we think.

Her work has added the weight of science to Hamlet’s observation;

“[T]here is nothing either good or bad, but thinking makes it so.” Shakespeare W. Hamlet Act 2 Scene 2:250.

Dweck’s ground-breaking studies have established that we all fall into one of two mindsets; either the fixed mindset, or the growth mindset.

For folks of the fixed mindset, intelligence and potential are set. If you happen to be genuinely intelligent, this is lauded for much of your formative life, and you can pretty much coast through the vast majority of formal education hoops without your pride, ego or abilities being properly challenged.

If you have a fixed mindset, when the challenges come – Dweck’s research shows – that people will refuse them in order protect their cultivated reputation, to protect their fragile ego, rather than risk looking foolish, stupid or even not quite living up to their own opinion of themselves. That is, in the fixed mindset, effort – and the potential failure that effort entails – is seen as a threat to intelligence, and hence avoided.

But for people with the growth mindset, we can all improve. Be that our understanding, knowledge, attributes or skills. Or even raw intelligence. We can do better. No matter if you’ve started at the top at the class, middle of the pack, or at the bottom. The growth mindset means acknowledging that you could stand to know more, to be better that you are right now.

And the secret to improvement is failing. By seeking out more and more challenging problems, mucking them up, and then learning from the experience.

When we seek out failure, we grow. And, best of all, the growth mindset can be imbued in us. We can force ourselves into this mindset of growth. And this is really the crux of what I’m talking about. That when it comes to failure, if you have a growth mindset, it’s just another opportunity to learn.

Take home points:

  1. Failure is for everyone.
  2. Embrace failure; you don’t need to be a Greek God or superhero to overcome failure.
  3. Use failure; to turn pro.
  4. Seek out failure; it’s part of a growth mindset.
  5. Failure is just another opportunity to grow.

You can hear more about dealing with failure on the always excellent EM Cases with Anton Helman and guests, Sara Gray and Chris Trevelyan.

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