Jarrod Shapiro, DPM
Practice Perfect Editor
Assistant Professor,
Dept. of Podiatric Medicine,
Surgery & Biomechanics
College of Podiatric Medicine
Western University of
Health Sciences,
St. Pomona, CA

Grit and Bear It To Succeed

When I was about 14 years-old, I started taking guitar lessons. When my lessons started, I wanted to play the guitar solo from the movie Top Gun (1986). I know, who'd want to play that? But recall, it was the most popular movie at the time. Unfortunately for me, I quickly learned that this song, as simple as it sounded, required a much more advanced level of knowledge and skill than I had. Instead, I learned a few other "easier" songs (they were actually quite challenging for this novice guitarist). What I hadn't realized while I was thinking about all those famous guitarists who made playing their instrument look so easy was that they had spent years learning and then honing their craft. I stopped playing the guitar after one year.

Fast forward to the present. My 8 year-old son is a budding dancer who has spent the last 2 years becoming increasingly serious about this pursuit. It started out much the same way that my guitar playing did: he watched a few episodes of the dance show So You Think You Can Dance, and decided he wanted to be on the show. His fantasies never included all of the years of hard work and dedication the kids on that show needed to get to the top. My son, though, different from me, did not give up. Instead, he stuck with dance, even joining a Company of competitive dancers.

Advanced skills are not possible without mastering the basics Now he is to the point where he is on the verge of doing increasingly more advanced dance techniques. The problem now is he wants to do those more advanced moves without having to do some of the grinding preliminary work. For example, dancers require a level of flexibility far beyond the average person. I'd hazard a guess that the prevalence of equinus is quite rare in the dance world! This requires often uncomfortable stretching for prolonged periods of time, time that my son does not have the patience for. His mother and I recently had a "motivational" conversation with him to try to open his eyes to the necessity of completing the hard work before doing the "fun stuff." In short, he needs grit.

Tonight's Premier Lecture is
Opening vs. Closing Base Osteotomy -
Is There a Controversy?
David Davidson, DPM

By no means is this desire to skip the boring and often difficult preparation unique. All of us would like to move straight to the leaps and spins. And this is no less true for my podiatric students. All too often, my faculty and I receive requests by our students to have lectures and workshops on topics for which the students are not yet ready. For example, a somewhat popular club lecture for our early students is to show a surgical video while a faculty member narrates and comments on the procedure. Of course, many of the students barely understand the videos, much less the indications for these procedures, because they haven't yet done the leg work necessary to truly understand what they're looking at.

I tend to see the same thing in some of our more advanced students. Most of my third and fourth years, while rotating through our service, speak very highly of the attendings that let them do more during surgery. Many of them, though, fail to grasp the necessity of being able to do the basics. Our dean, Dr. Harkless, advises students to practice suturing at least 10 minutes per night, yet it becomes immediately clear which of them have taken that advice to heart, once they get into the OR with us. Why would I let a student or resident do a skin-to-skin procedure if they fail to demonstrate skill with the most basic of operative skills?

The hard truth is that the advanced skills are not possible without mastering the basics. For my son, that means stretching repeatedly, gaining strength, and mastering the elementary skills that will allow him to perform advanced artistry. For our students, it means making sure they have a strong grasp of, first, anatomy, biomechanics, and basic podopathology, then learning patient care fundamentals, suturing, and OR skills (protocol and basic surgical methods such as tissue handling), and finally, the more advanced surgical techniques.

Staying true to this necessary step-wise approach requires grit and an ability to focus on the skill at hand and not try to leap ahead of one's level. But how do we as teachers, whether clinical or surgical, keep our neophytes on the right track? Here are a few suggestions to help bring our trainees along and help them succeed. I've learned the following by watching other teachers far better than me.

First, hold them accountable for the preliminary skills. Test your trainees on whatever basic skill you want them to know. If, for example, your resident doesn't understand the pathogenesis of adult acquired flatfoot when you quiz them, then don't let him scrub the surgery. Similarly, if your resident doesn't know the medical history of your surgical patient, then don't even let them in the room.

Second, consider using a written checklist. Make a list of progressively complex skills your students should have prior to moving to the next level. For example, a student should be able to describe the nerves of the foot before performing an ankle block.

Third, employ the anticipatory set. The anticipatory set – my wife calls it prelearning - is an educational term in which the teacher introduces basic information and new concepts at one point and then returns to the same topic at a later date, but with increasing detail. Think of this as providing a "hook" to grab attention and maintain interest. The local ACFAS club at Western University, for instance, asked me to do an introductory lecture on the operating room and how to best succeed in this environment. For a first year student, this lecture will not be highly useful except to show them where they will be in the future and help motivate them to continue the work necessary to prepare for their clinical rotations.

Fourth, lead by example. As an experienced clinician, speak to your novices and relate how you were once in the same position as them. Describe what you did to master the basics. What did you do to succeed? How much grit did it take you to get to where you are today? Explain the importance of persistence. Take whatever opportunities you have to motivate your students and residents to focus on the basics before leaping into the advanced. I recently did a percutaneous Lisfranc reduction and fixation which impressed a couple of students. I took the opportunity to relate the importance of understanding basic anatomy, specifically surface anatomy, before performing percutaneous procedures.

Do your trainees know the basics? How do you know? Make them prove to you first hand their mastery of the fundamentals before proceeding to the advanced work. Most importantly, teach them the importance of grit in order to be successful. Remember the old adage, one must walk before she runs. Good luck with your next teaching experience.