When I was a medical student, I was haunted by Jeanine Chalabian, MD. I never knew her, but she has affected me in a way that was as profound as any living mentor and friend, a guiding light for how we could be more creative in educating future surgeons.
I first developed a bond with her during my surgical clerkship in November 1999, where we were given booklets for an interactive learning module on how to perform a vascular exam. These case-based workbooks allowed you to learn at your own pace and had more graphics than words, with photographs and illustrations of angiograms and venous stasis ulcers. I was so thoroughly entertained while achieving my learning objectives that I needed to know more about their origins. As I turned back to the cover, I saw her name and realized she was gone too soon.
Dr. Chalabian was fatally shot by her husband only two years prior in 1997, when I was a first-year medical student. She was a surgical resident, and chose to dedicate her research years to the pursuit of a PhD in educational psychology and technology. This was before the 80-hour workweek and simply not a time when surgeons focused on surgical education. She was a mother of two who chose a creative career path and had a bright future, being instrumental in securing multimillion dollar funding to establish a surgical skills center at the University of Southern California, Los Angeles—no small task for a trainee. For some strange reason, in that moment of flipping through a throwaway handout that allowed acquisition of lost data for an otherwise forgotten publication,1 I became inspired by her work and found myself looking up to her creative spirit and considering how that melded with a career in surgery.
A few years later, I had nearly forgotten her name, but rediscovered her through Google and PubMed. While I was a lab resident writing up a research paper on surgical simulation [forgotten citation], I paid tribute by citing her fantastic work on motivation theory.2 I was elated as I read the first lines of her paper: “Critical to any resident’s success is that individual’s commitment and desire to succeed. The most significant predictor of high levels of success or greatness in sports is an athlete’s attitude or motivation.”2 Absolutely. I recalled Maslow’s hierarchy of needs, a pyramid I chose to topple in order to become a surgical resident, and continued to relish sleep deprivation, relative financial insecurity, and pragmatically, occasional food scarcity and the denial of bathroom breaks, all for my own self-actualization.
But how do we know that people are truly committed? How do we know they have grit—that they can keep their head up in the face of failure? We can only speak for ourselves, and then realize there will be situations where we are surprised to find ourselves burnt out and need to take a step back. We strive for an ideal of surgical proficiency and good judgment, but then forget to remind ourselves that even that takes time and polish.
Intrinsic to surgery is the presence of error, and we work to minimize those error bars through increasing our sample size. But ultimately, we find that only “the gritty” succeed because they can learn from and adapt to bumps in the road and keep on trucking forward.3
Jeanine reminded me that “Motivation is analogous to gas in the tank.”2 Chalabian wrote her manuscript shortly after the 1996 Health Care Financing Administration (now the Centers for Medicare & Medicaid Services) regulation that physician fee schedule payments for procedures would only be available if the attending was present during the critical portion of the procedure, and she predicted that this regulation would challenge resident motivation.2
In the paper, she describes development of surgical maturity and independence requiring a balance between supervision and autonomous experience. Under the framework of Albert Bandura’s social cognitive theory, an individual has to believe oneself as capable of successfully performing a task to be able to actualize that goal. “Surgical self-efficacy” is related to: (1) a choice to engage in an activity, (2) the quantity of effort invested, and (3) a willingness to persist. She cited Salomon’s inverted U-shaped curve, a hill where at the apex is a sweet spot where an individual will expend a maximal amount of effort for a given amount of perceived belief in one’s success. Too much or too little stress, and the trainee will tip off and stop caring—motivation declines.
For a resident with low self-efficacy, a step back with remediation may become necessary to improve the resident’s skills and confidence level. Residents with high self-efficacy may need to be given greater autonomy through teaching-assistant roles or challenged in other ways to keep their motivation high. Surgeons require self-directed behavior to excel, fed by autonomy, mastery, and purpose,4 but the trainee has to receive the right kind of feedback to learn to push forward.
In the paper, Dr. Chalabian continued her discussion by citing Bandura’s theory of reciprocal determinism, where a person’s behavior both influences and is influenced by personal factors and the societal environment, a big triangle of codependence.2 Here she suggested that surgical self-efficacy can change based on post-call status, perceived difficulty of a case, and even the attending, hospital, or team attached to the patient. With the decrease in resident autonomy, residents with low self-efficacy may become plagued with self-doubt and may give up more easily when confronted with future difficulties, particularly when they are not supported by their environment.
In her concluding paragraphs, Dr. Chalabian provided strategies to help improve resident motivation in an era of decreased resident autonomy and increased financial pressures on teaching faculty. She suggested to stop residents from focusing on who is “doing the case” by breaking the case down to goals where the resident learns how to do a specific skill in a different way or changing focus to improve upon a prior performance of a specific task. She stressed transitioning the resident to self-regulation, a situation where as their “expertise develops and performance improves, his or her ability, effectiveness, and willingness to take responsibility for subsequent learning and performance increase.”2 She then closed her paper, which was published posthumously in Surgery, with the following mission statement:
