Selecting grittier surgeons is harder than you think

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

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

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

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

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

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

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

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

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

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

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

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

Here’s another issue.

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

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

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

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

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

“Skeptical Scalpel” is a surgeon blogs at his self-titled site, Skeptical Scalpel.

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  • John C. Key MD

    I am sorry to read that grittiness is passé, though I suppose it isn’t surprising if one surveys current culture. I think that to be a good surgeon one must first have grit.

    Forty years ago we all tried to feel gritty. I trained at a large private clinic where the workload was heavy but all was pretty clean and refined; my colleagues and I were always trying to make ourselves seem and act tough though we knew we weren’t the steak-for-breakfast types such as one found in DeBakey’s Baylor program.

    I hope the profession can dig up some more grit. Any student of surgical history will see in short order that surgery has emerged from a gritty crucible, not an easy one.

    More 36 hour shifts please.

  • Markus

    Now that we have a solution (more grit!), what is the problem that we are going to solve? Are we supposed to change long standing practices on the basis of a questionaire that did not reach statistical significance?
    Good surgeons combine wisdom, skills, judgement, scholarship, and coolness under pressure. In my experience, the vast majority achieve these goals the vast majority of the time. I salute them. They are human and sometimes slip, but that is actually uncommon. Sometimes, they are a little self-important, but that just allows me to exercise my skills at mocking.
    Of course we were tougher forty years ago. We volunteered for extra call and walked to the hospital uphill through great mounds of snow carrying textbooks that weighed 120 lbs.

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