Moving Beyond A Fixed Mindset in Medicine

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Growing up in both the US and Germany, I’ve been a firsthand observer when it comes to the differences between school systems. There are the different takes on school lunches: corn dogs and sloppy joe versus potato pancakes and eggs in mustard sauce. There’s the German preoccupation with ergonomically correct backpacks- one that some might call excessive. (In Germany, school bags cost several hundred Euros and children obtain a license before wearing them lest they strap them on incorrectly.) There are the differences in school-related celebrations. Every German child receives a Schultüte on the first day of school, a handcrafted gift inexplicably shaped like a giant cone and filled with an abundance of school supplies, toys, and candy. Meanwhile, in the US, elaborate ceremonies are held with all the gravitas apparently necessary to commemorate elementary and sometimes even preschool graduation.

And then there are the grading systems. It’s not just that the US uses letters while Germans, predictably, choose numbers. It’s the entire way grades are distributed. The guiding principle in the US seems to be everyone is awesome, while in Germany receiving a ‘1’- the highest mark- is pretty much reserved for third graders able to spontaneously compute the Gaussian integral.

Germans are notoriously restrained in their praise. If you’re worried I may be offending my German readers, rest assured there is no cause for concern because a.) I know all five of them personally and b.) Germans take great pride in their candor. If there’s something Germans regularly look down at Americans for, it’s their degree of enthusiasm, which is regarded with the utmost suspicion.

There are no ‘honors’ handed out in the German school system. This isn’t Oprah. Everyone doesn’t get an A. You can’t score 104 points on your spelling test because of ‘extra credit’. And don’t even get me started on gold stars.

I used to think Germans are just grumpy. (My husband likes to point out that I, too, am German but the nice thing about dual citizenship is that you get to pick which attributes you want to identify with). Lately, though, I’ve started to consider that they may be onto something.

Here’s why.

In ‘Mindset’, psychologist Carol Dweck lays out a convincing theory that success comes down to what mindset you have. The fixed mindset believes that our traits, skills, and abilities are mostly set, with little room for improvement. The growth mindset, in contrast, believes that our talents can always be developed.

Mindset is an essential quality in a physician. The practice of medicine requires constantly stretching oneself and thus requires doctors to actively embrace challenge. Unfortunately, a career in medicine tends to facilitate a fixed mindset. The selection process that determines who will become a doctor centers heavily on static indicators such as grades, test scores, and class rank rather than someone’s overall learning trajectory. And once we progress down the medical career path, the fixed mindset continues to be reinforced through further recognition of outward achievements rather than a demonstrated commitment to continual learning and improvement.

So what happens when the fixed mindset reaches the hospital? Rather than welcoming new ideas, input and approaches, the fixed mindset resists them. This resistance manifests in multiple ways.

A doctor intent on proving him or herself may, at first glance, seem like an asset. Wouldn’t it make them work that much harder, be that much more committed to achieving the best outcomes? The reality is, in the hospital, an overwhelming desire to prove oneself can be a dangerous thing.

It may lead to an unwillingness to accept questioning, whether from more junior colleagues, other team members, or patients and families. But it is exactly that questioning that prevents us from overlooking options we had failed to consider, helps us weed out false assumptions, and keeps us from falling into the trap of cognitive biases that impair our medical judgement. There is a straight line from this unwillingness to be challenged to an overemphasis on hierarchies, which is particularly pronounced in the German medical system, and a reliance on eminence-based medicine.

The need to constantly prove oneself also results in an inability to openly admit to and address mistakes. Human nature dictates that mistakes will be made. Viewing them as an indictment of our inherent capability as a physician hinders us from using them as an opportunity for improvement. (More on our flawed culture around errors in medicine in my article for BMJ Opinion.)

Another way we see the signs of a fixed mindset play out in the hospital is the all-too-common resistance to adopting new approaches or abandoning approaches that have been proven ineffective. Medical knowledge is increasing at an unbelievable, unprecedented rate. The fixed mindset becomes defensive at the idea that we may have gotten it wrong in the past. The growth mindset, on the other hand, embraces the challenge of constantly unlearning what was previously true and replacing it with more effective strategies. It understands that, for as long as we practice medicine, our knowledge will never be complete and is heartened by the unremitting progress this signals.

Lastly, the need to prove oneself creates an environment in which physicians undermine each other in an attempt to establish their own superiority rather than working together towards the overarching goal of better patient care. (You can read more about these patterns of behavior in The Subtle Signs of A Toxic Work Culture- Part Two.)

Knowing that our medical training has conditioned us toward a fixed mindset, the question becomes: How can we counteract this tendency? And how can we cultivate a growth mindset in future generations of doctors?

As with so many things, simply being aware of this propensity in ourselves can go a long way toward mitigating it. Having recognized my own fixed mindset, here are some of the ways I intend to dismantle it going forward:

Ask more questions. I didn’t use to ask questions unless I was pretty sure I already knew the answer. Having been stamped with the label ‘smart’ early on, I was afraid of asking questions that revealed my lack of understanding. Now I realize how much smarter I could have made myself simply by asking. The good news is, I haven’t run out of questions yet.

Allow yourself to be challenged. As a senior resident and later as an attending, I thought had to have all the answers. Looking back, I recognize that was my fixed mindset speaking. I’m not saying I will enjoy having someone question my reasoning or my decision-making henceforth. But I do want to push myself to reframe it as an opportunity- one in which I have more to gain than I stand to lose.

Reconsider the status quo and delight in the changing guidelines and recommendations. It’s tempting to think once we’ve made it through the grind of medical school and residency we can finally rest on our laurels, and easy to get frustrated when we find this will never be the case. But if we come to see our role in slowly moving the needle forward through the process of trial and error that is, in fact, science writ large, we may even learn to celebrate our so-called failures.

So maybe Germans aren’t just grumpy. Maybe telling our kids their hard work won’t always earn them top marks isn’t such a bad thing after all. Maybe by doing so, we are teaching them to stretch themselves, to dig in, to reach for what may always remain just out of reach. Like figuring out that elusive diagnosis. Or curing a previously incurable disease. Or getting a ‘1’ on their third grade math test.