The Merits of Mediocrity: Rethinking Excellence in Healthcare

Promising Young Surgeon discusses how doctors approach their work

Dr. Frances Mei Hardin: Welcome to this week’s episode of Promising Young Surgeon. I want to talk today about how so many of us, as doctors, nurses, really, all health care workers, approach their work. There’s this idea that everyone needs to be excellent, and that falling short of this standard is unacceptable. Just about every hospital or program mission statement will mention some version of excellence in care and maintaining a standard of excellence. But how, as individuals, do we actually get there? Is the answer to study 24/7 practice hours and hours every day, never taking a day off, beating ourselves up until we’re perfect. What if there was another approach, and perhaps an even more effective one, one that could actually yield true excellence, but may in fact lead us to be more well rounded people and to achieve our goals more efficiently? So I’m about to say a, dirty word, something that has basically been scrubbed from the dictionary of acceptable language for physicians. Mediocrity. How can we accept the idea of mediocrity when there are lives at stake in what we do? Well, maybe we’re just looking at it the wrong way. And that’s what we’re here to discuss today.

Colin Royal defines mediocrity in relation to excellence in healthcare

So, mediocrity is an idea, it’s a way of life that I have read about. And Colin joins us today to do a deep dive. Colin, how would you define mediocrity?

Colin Royal: yeah, so I think you want to look at mediocrity in relation to excellence. So, like you said, excellence is something that’s sort of thrown around and is very common, specifically in healthcare. But I mean, in a lot of careers and in this kind of modern age, there’s, a way for mediocrity, right? Like you said, it’s kind of like a dirty word. So, basically, if you think of excellence as, let’s say, optimization towards a finite goal. So there’s one specific thing you’re trying to do, and you are optimizing to get to the 99th percentile, the 100% best you can do in that specific thing. This is going to use up basically all of your possible resources for that specific current goal. Mediocrity is kind of the opposite of that, in the sense that it allows for excess, at least a slight amount of excess, which can give you the ability to explore new things. it opens up the door to creativity, and it also sort of passively plans for the future. Right? So if excellence and optimization is for this, like in current time, finite goal, then mediocrity keeps the door open. it allows you to kind of have 1ft in, 1ft out, kind of gives you that flexibility.

Dr. Frances Mei Hardin: So I feel like I have to say, and I have to start out and be like, you know, I’m not the bad guy here. I, am a practicing head and neck ENT surgeon. You know, Colin is going to try to convince us about this whole mediocrity thing. Okay. I’m definitely here to raise the questions that I am naturally going to have about that as a surgeon. You know, this is like such a really exacting, detail oriented, granular, critically important work that we do. But it’s interesting because even as you kind of are defining it there and talking about that, well, then I start to think, what is the functional or meaningful difference between being like a 95th percentile ENT physician or a 99th percentile ENT physician? And I start to, you know, I start to wonder, and I’m thinking to myself, like, even while you’re talking about this, I’m thinking, okay, for instance, somebody who’s out in practice, they could spend 100% of their free time reading every week’s JAMA, attending every national or regional conference on the topics, making sure that they are just up to the hilt, like ingesting all of the new and up to date information and reviewing all the old information and just like, absolutely eating it up. But it’s like, if we could trade some of that time and those finite resources to learn new skills that augment our practices. Okay, that’s an attractive thought. You know, I would have interest in that.

Colin Royal: Yeah. And I would even push back more because you said, you know, the 95th percentile, right? I think it’s, what is it, like Dunning Kruger effect, right. That everyone basically overestimates their own skill? I’m probably getting a little bit wrong, but that’s kind of the principle of it. The idea of excellence, like as it’s use today is probably just kind of wrong, right? In the sense that if you’re literally talking about within the cohort of ents, you’re striving to be the 95th percentile. I mean, yeah, that’s, that’s really high, right? Like there’s only so many ents. That means you’re a literally top, you know, hundred ent, whatever it is, like in the entire country. that itself is probably too far, right. You’ve spent so much time optimizing for this one skill that you’re even probably past the point, well past the point of diminishing returns. Whereas really, like, when you think about excellence, it’s actually pretty like to the outside of observer, it’s probably. It looks like excellence, but if you’re in that level, it’s probably actually average. Right? So.

Dr. Frances Mei Hardin: And I. Yeah, I get what you’re saying because, like, realistically, you’re totally right. I wasn’t really thinking about that, where it’s, like, stratified just by. Okay, like, this specific specialty, all those physicians. Because, yes. What you’re saying is that there have to be, by definition, a ton of physicians who are, like, 50 if percentile physicians, obviously. you know, that. That rustles the feathers. Like, I can’t imagine any physician who’d, like, proudly walk into a room and be like, what’s up, guys? I’m strong. 50th percentile. Like, of all oncologists, I’m here to say hello. You know, that’s terrifying. People would be like, oh, my God, I want a different doctor. But I agree with you that, like, realistically, if you did get that 50th percentile physician, I could imagine where externally, you know, where they’re viewed by their staff, their patients, things like that. Like, people would be like, that’s an excellent doctor. I love that. Man or woman.

Colin Royal: Yeah. Because even if you literally are the, you know, just dead middle 50th percentile ENT in the country in the specific area that you’re practicing or the hospital that you’re in, it’s not going to be a lie to say excellence in ENt. If that’s, like, your marketing slogan to the general public and even to some of the other doctors in the hospital, that’s going to hold true, because they’re looking at this level that they’re not really aware of and thinking, oh, this is excellent behavior, or this is excellent surgical skills or whatever it is, but within the groups of ENTs, it’s actually kind of middling behavior. Right. You’re down the middle. That’s kind of how you have to think about spending your time striving towards excellence in one specific thing, because it’s just, you know, you can only go so far, and there’s pretty rapidly going to be a point of diminishing returns where you’re just banging your head against the wall trying to get to this 95th percentile and, like, letting all these other opportunities kind of go by the wayside.

Dr. Frances Mei Hardin: Right? And I definitely, like, like I said, that’s an attractive thought. Like, of course, I don’t want to spend undue time beyond the point of diminishing returns, you know, I would imagine, like, a lot of doctors feel spread thin, pulled in different directions. So, you know, of course, like, you have my attention there. But when you do talk about how people can lower their standards to achieve growth and things like that, it sounds paradoxical, honestly, it is, like, straight up a little offensive. Like, it’s just, it’s so hard because it’s ingrained in us as physicians to not accept any lower standards. And, you know, like I said, like, the work that we do can be life and death, and it’s certainly health and, and it’s so critically important. So just even. It’s funny because a lot of this language even has, like, emotion tied to it. And so I’m willing to hear your logical, whatever you have to say about this, but I already bristle. Yeah, okay.

Colin Royal: Yeah. And, you know, I think most would, but it really is like a matter of kind of reframing how you’re thinking about the idea of excellence, right. Because, I mean, surgery is probably the best, you know, scenario to think about this. And in that you literally cannot drop below a certain standard, right? Because if you show up in a life or death situation and you drop your standards so low that, let’s say you were just messing with a spreadsheet, whatever. So that spreadsheet doesn’t work quite as well, but in this case, someone might literally die. So there is a specific level that you have to stay above, and probably some room above that where you would want to grow beyond just the bare minimum, obviously, to have consistently good outcomes, as well as to gain the reputation that you’re a trusted surgeon and, you know, people, right?

Dr. Frances Mei Hardin: So there’s a threshold you have to exceed, and then there’s a range that maybe is an ideal range, and then there’s going to be another point where you keep going past that, and that’s the point of diminishing returns.

Colin Royal: Yeah. I mean, so if you think about it in like, the, like a training, you know, setting, right, in residency, I mean, you have to learn a lot of different things. You gotta learn a bunch of different procedures, even just medical management, right. There’s gonna be tons of different things that are coming up against, you know, your finite amount of resources. I mean, it takes a bit of finesse and kind of creativity to understand, like, what that level is. But if you think about everything as kind of like, you know, steps or a ladder, when you are close enough to that top step, rather than trying to, you know, kind of take that, that graduated, you know, upward curve, like, to the next step, you just say, you know what, I’m good enough on this step. I’m going to jump to the next one. I’m going to move on. I haven’t maybe mastered that technique, but I’m pretty good. I think I will, with some repetition, get better at it over time.

Part of lowering standards is giving you the ability to fail

I’m going to move on to the next thing.

Dr. Frances Mei Hardin: So how practically does that work with lowering standards?

Colin Royal: The idea is to kind of half ass it in a way while you’re able to figure it out. And part of this, too, is giving you the ability to fail. So if you are spending so much time optimizing towards this one specific skill or whatever it is, it might be that you’re just actually not that good at it, and you’ve now wasted tons and tons of time, tons of resources, and you just keep thinking, I just got to keep pushing through. I got to keep pushing through. But if you’re adopting this other mindset, there comes a point in time where you say, hey, you know what? Maybe this just isn’t for me. I want to pivot and do something else. Right. It doesn’t mean you can’t be an ENT. You might just say, you, know, I don’t like ear surgery that much, right? I’ve done a decent amount of this, and it’s just. I’m okay at it. It’s. But it’s just not my. My specialty. It’s not something I’m really loving. So let’s move on and try something else. You know, you have to be able to pass that piece of it. But is that going to be right, your forever thing? Probably not.

Dr. Frances Mei Hardin: Well, I actually feel like when you do talk about that point, like, let’s say that somebody is in the range of competence. I guess we could call it, like, the range of competence, because, like. And, depending on how you define excellence, you’re in there, but you’re in that, like, middle percentile. But one way in which, like, I can even see some elements of this coming into play are, that, you know, I’m a couple years out in my practice, and that first year after residency, that is a pretty high stress time. Like, of course, the learning curve is very, very steep on that. And even though, yes, you’ve been training for many, many years, it’s like doing everything on your own for the first time. And in my experience, I started a solo practice from nothing. Like, I, received an empty office space and kind of like, you know, a list of items that can be ordered from McKesson to stock an ENt clinic. And, you know, I picked out chairs for the ENT clinic and things like that. So m that first year, it really, in my. From my experience, it just took so much to make absolutely sure that everything is worked up appropriately, correctly, safely, to make sure that nothing’s missed, to make sure that, like, system processes are in place, and that one is really, like, you know, on their own, practicing all these. All this medicine in clinic and also operating in the OR. And so that was, like, very all encompassing. That was an extremely, demanding time. And a lot of people talk about the first five years out in practice as being that way. They kind of say, okay, after five years out alone, you really, like, you should have it quite down pat. Like, you should be feeling good then for the next 1520, whatever it may be. But what’s interesting is that I can even see a huge difference within these first five years, like the early career, you know, timeline. Because after that first year, okay, I started to be able to have a lot of spiels, for lack of a better word, like down pat. And, you know, I’d use the example of, of course, we get tons of referrals for older patients who have presbycusis, which is natural hearing loss that comes with age. Like, imagine a bilateral, both sided sensorineural hearing loss. That’s the type that we all get with wear and tear, noise exposure, you know, again, hearing loss of aging. And that often comes with some variant of, let’s say, they also have tinnitus or ringing in the ears on both sides. And so if they come in and see me as a new patient, and there’s no asymmetry to the hearing loss, and there’s no red flags at all on their audio and tips, like, this can be a very straightforward type of thing. And, you know, that spiel. Imagine things like sub centimeter thyroid nodules. Like, there’s just so much in the ENT world where, yeah, the clinical management is quite straightforward. It’s all really very algorithmic. Sure, maybe. Maybe once a week, something quite shocking or very new in terms of pathology will walk in. and there’s so much variety in ent, and so absolutely, like, we do see that, and I appreciate that. But there’s so much that is down pat that’s still like, yes, I already have done this now over a hundred times. And, you know, with that comes familiarity with all that.

I think there’s a benefit to physicians lowering standards when transitioning into practice

And then I guess that instead of going from a couple extra percentage points on how good of a spiel you do on presbychusis, I have been able to spend a little bit more time just reading books of interest to me. And one example I would use is the charisma myth, which I recently read, and I really enjoyed it because the myth is that people are either born with charisma or not. And, you know, this woman just kind of takes the time to systematically debunk that and then also train the reader in ways to practice, you know, utilize more charisma ways to win more charisma points in any interaction. And another book that comes to mind, too, actually, that I really loved within the past couple months was, the french art of not trying too hard. And that is, of course, like a self help and lifestyle book. But it was so wonderful. And I guess that, like, it was wonderful and it really offers a different angle at looking at life, which you can kind of imagine is also like the antithesis of being a doctor or becoming a doctor. I would say the anti Tome is the french art of not trying too hard. But, what I would basically say is that I can see benefit to physicians broadening their horizons in ways like this. I mean, neither of those books really have anything directly to do with clinical medicine, yet. They could take a doctor, really, to the next level, I think, even in practice of medicine and surgery.

Colin Royal: Yeah, you, probably didn’t even do this on purpose, but your example of, like, practicing, a spiel for, like, little old ladies who can barely hear you. Yeah, that would not be a great use of time because they could barely hear what you’re saying. So that is definitely like, get your, you know, function over form. Just get it out as good as you can and, you know, move on to the next thing. But, yeah, I mean, I do think, you know, especially when, you’re, like, thinking about making a transition from, like, medical school or residency into practice. Like, you don’t have to really compete with people once you’re in practice. I mean, sure, there’s maybe some small departmental competition or whatever, maybe some fighting over patients or whatever, but it really doesn’t have anything to do with your skill necessarily. So you spend all this time in training in medical school, showing your elevated level of knowledge and how good you are at everything. But then you get into practice and you have to convince patients who have no idea what you’re talking about that you are confident, you know, you know, you have the answers and you’re going to help them. and those are just very different skills than, you know, studying, and practicing your surgical technique, like we said. I mean, obviously you have to get to a certain threshold to be able to function within those. But there’s just many, many other aspects that are going to become way more important as you kind of get out, like, into your own practice.

Dr. Frances Mei Hardin: And if everybody did adopt this mindset, lowering their standards and striving for mediocrity, you know, obviously the feared. The feared outcome would be that there’s mediocre everything. And so, of course, like, I wouldn’t want to receive mediocre healthcare. I would not want to eat at a restaurant that has mediocre service.

Colin Royal: Yeah, it’s, important to realize that if you are thinking this about something, right? Because this is kind of all relative. So if you’re showing up to a restaurant or a doctor’s office and you’re saying, you know what? This was just really mediocre. Everything I got, honestly, maybe it is, maybe it’s just bad food and, you know, they’re just being sloppy. If that’s true, they’re probably then going to go out of business, you know, relatively soon. If just nobody likes it, they’re just doing a bad job. But in reality, what might be happening is that that system, organization, whatever it is, is actually optimizing for something else in a restaurant. That server, you might say, hey, that was mediocre service. I really didn’t like it. They’re probably not worried about spending a lot of time and getting the absolute best experience for you, because maybe their game is high volume. I want to have as many tables as possible. I know that no matter how good I do, they’re probably not going to leave more than a 25% 30% tip. So I would rather take a 15% tip from every table and double my amount of tables I can cover versus really focusing on six to eight tables per night. so in that sense, understanding where that vested interest is within the organization, kind of allows you to see what the end game is and understand the level that those people are playing at. So it might not actually be a mediocre thing that, you know, you’re witnessing here. It might actually be quite optimized for a different goal.

What happens when people start to be mediocre at work

Dr. Frances Mei Hardin: Okay, so what practically happens if people start to be like, quote unquote mediocre at work? Like, obviously one would worry about getting in trouble, getting caught, getting found out.

Colin Royal: Again, like, obviously there is a certain threshold, right? And a lot of that’s gonna be very situational. So you’re gonna have to see what’s acceptable within either your training program to your peers. You have to be somewhat on the level to kind of keep it going. But basically, if you’re sticking to these rigid, really high standards. Whatever it is, it’s going to keep you really locked into the present. So, potentially more dangerous than flirting with the edge of mediocrity, getting in trouble a little bit is that you are honestly very likely to get stuck in a certain paradigm. Right. You’re very likely to get stuck in the present there, to where it’s going to make it hard. You might get through that specific trial, test, whatever it is, but as you continue in your career, you’re probably really going to be stuck at that point where you spent all of your resources and all of your learning on one thing. Right. medicine is very much a changing environment, especially. I mean, it’s going faster and faster now, right. There’s new drugs, new techniques, new whatever it is, new studies, findings, everything that’s sort of advancing, your specific specialty practice. and the. The striving towards excellence in a certain thing is going to probably keep you stuck in the past. yeah.

Dr. Frances Mei Hardin: Or like on a hamster wheel, I guess, what that feels like, too. And I just think that this reminds me of a lot of arguments that I make about teaching DBT, dialectic, behavioral therapy type informed skills to medical students. Yes. It’s not anatomy, it’s not like a dissection lab. It’s not a textbook learning type of thing. But those are skills where if you were planning for the future, like, I can tell every student that they are going to need skills over the next several years and really their long career, hopefully, where they have excellent interpersonal effectiveness skills, like they’re able to get from other people what they need from them, number one, while maintaining a positive relationship with them, number two. But that’s such an example of kind of like a soft skill that’s very much outside of the textbook clinical skills and clinical practice workbook.

Colin Royal: Yeah. And that’s just so often not prioritized by a training department. Right. If you think about what would be considered sort of a malignant program, likely, what is happening is that who’s ever kind of setting the standard for that is stuck in this excellence mindset, right. Where they have extremely high rigid standards, but to a very specific thing. And that might not be, especially if it’s like two generations removed from the people that are practicing, that might not be what this whole cohort of residents or med students is trying to get to. So you really get this conflict that there might not really be a way out. Right. You get stuck in this sort of authoritarian environment to where the only option that you’re given is to expand, expend all of your resources towards this goal that, frankly, might not help you as an individual.

Dr. Frances Mei Hardin: That’s true. And there’s a lot of residency and medical training, being a medical student resident fellow, all of it where some of those tasks I actually do think may fit nicely under that thought. For instance, patient transport, phlebotomy. I used to occasionally get sent down to the mail room to search for an instrument that was supposed to have arrived two days ago, and now the patient’s already in pre op, and, you know, we’re about to roll back for surgery, and no one can find this object. So there are some kind of even, like, clerical tasks where. Yeah, I guess, you know, transport of a patient should just kind of be transport of a patient. I would actually accept being the 50th percentile level at that. That. At that task.

Colin Royal: Yeah. interestingly, like, yes, a lot of. So, you know, patient transport. Right. That’s probably never going to help you, but in some ways, like, having part of your training be some of these extra administrative type stuff, it’s actually probably going to be helpful for you. Right. Because let’s say, like, the rule of your training was we spend all of our waking hours in clinic or in the operating room. That’s it. We have staff. They do everything else. You know, you guys don’t do anything. You don’t write your notes. Like, you just, you know, scribe them, like all that stuff. And then you get out into private practice. And now, like, you, for instance, I mean, you start a brand new practice. You had to figure out how to get instruments. Like, you had to. You do a ton of stuff on your own. If you had just never had any experience with that, I mean, you’re a pretty resourceful person, but obviously, the track to becoming a doctor is just like college, medical school, residency, and now you’re a practicing doctor. Like, there’s going to be a lot of people that just don’t have experience.

Dr. Frances Mei Hardin: Yeah. Not much work experience.

Colin Royal: Yeah. Or just, like, having to be creative and, you know, because really, if. If the. The mandate was we are here to do this one specific thing over and over every day, it’s going to limit, like, your ability to grow and adapt in kind of a changing environment.

Dr. Frances Mei Hardin: Yeah. And that’s definitely true because, you know, in addition to furnishing the practice and picking out, you know, supplies for six months worth of work, which was obviously like a mathematical and hypothetical challenge, I had to build the schedule, you know, and that’s something that a lot of graduating physicians and surgeons are going to experience, especially if they are building something themselves, then it. It literally, you get a blank page and you say, how many patients are you able to see a day with? What time blocks per patient? And anyone who has ever managed a healthcare clinic schedule knows the absolute jigsaw puzzle. certainly in ent, too, I do a lot of scopes. So with scope visit or, which is, for those of you who haven’t been to an ENT clinic, we do, like, laryngoscopy, as well as nasal endoscopy. Those are different procedures to kind of basically, really quickly in clinic, look at the larynx. You could look at the vocal cords. Certainly anyone who says they have, quote unquote, hoarseness or dysphonia, chronic throat clearing, things like that. Nasal endoscopy is great because we do things like look forward nasal polyps. We look at purulence coming out of the nose. And, you know, I can take cultures in clinic, but the point just being that, like, when I had to train my totally new two ENT staff, like, we started at the beginning just to kind of talk about, okay, well, what are these procedures? You know, because they have tons of clinical experience, just not an ENT clinic. We do a lot of ear cleanings, ear foreign bodies. Like, what are the time slots for all these news versus returns versus a post op? And so I definitely do agree with you, and I think that getting adept at problem solving and, you know, scheduling administrative tasks, things like that, sure. Like, it has value, but I really, you know, I can see diminishing returns at that. Like, what’s the difference between somebody being 90th percentile incredible at jigsaw puzzles versus your 98th percentile jigsaw puzzler? I don’t know. Who cares? Life is short.

Colin Royal: Yeah. And that’s very much like, you just want to be able to do it, right. There’s no, like, excellence involved in that. And obviously, it can swing the other way, too, where there’s probably residency programs or any other job, right, where you actually get saddled with a ton of this administrative stuff, and it’s swinging so hard the other way.

There’s this whole mediocrity discussion about resident physicians

Or again, like we were talking about, where it’s like you’re marching towards this one specific thing, because who’s ever in charge has, you know, set those rules, and there’s really. You don’t see a way out. I mean, that’s kind of where this idea of, like, quiet quitting comes into play. Right. it’s. It’s being framed, you know, in. In the mainstream, as, you know, all, ah, these, these gen zers. Like, they don’t want to work, they don’t want to show up, but really they’re showing up and they’re saying, why am I in this office driving an hour to and from an office building to sit in a cubicle when I am just, like, given a laptop here? I could just bring that home, work at home, get the same stuff done, be less distracted. I probably do a better job, but I’m in this outdated model. my pay is not rising similar to residency. You’re stuck in this thing. And so what happens is people just sort of start to pull back and you say, you know what? I’m not going to optimize all of my time. I’m not going to spend so much time getting good at the skill that I’m not being rewarded for. I’m just being rewarded in the moment here. But I don’t see career growth within this. You know, I don’t see pay raises, whatever it is. So I’m going to do basically the bare minimum. I’m going to find that threshold that doesn’t, you know, force me to get fired, and I’m going to spend my time doing other things. I’m going to learn different skills, you know, I’m going to better myself in other ways that I see as useful, you know, to me in my career moving forward.

Dr. Frances Mei Hardin: And I think that I can just definitely relate to how difficult it is as a resident physician. You know, this was a challenge at the time to see, like, in front of, you know, beyond your hand, in front of your face. Like, I, it definitely was living in the moment, making it day to day and things like that. And also, of course, like, we are discussing multiple ends of this spectrum because take it or leave it, this whole mediocrity discussion. But I think that many people can agree that what is a huge problem is when resident physicians just hold themselves to this, like, extremely, maybe unrealistic, maybe unattainable high standard across the board. They are trying to excel in every single way, every single day, right? Like that. That’s kind of not any way to live. And like I said, I don’t know that that’s truly attainable. And one way where I think of this coming into play, especially as you talk about, like, somebody else’s optimality or the whole SEO thought, like, who are these systems built for and, like, who’s benefiting and what are you doing this task for and things like that. I mean, when I was a senior resident and, you know, making sure that cases that came in overnight or, like, trauma add ons and things like that got booked. I was just truly, you know, getting it on the schedule, getting an attending to cover it, making sure that it ran on time, making sure that it ended in time. Occasionally attendings would say, like, yeah, I’ll cover that trauma. Like, you can. You can book it under me to roll to the or, but I have to be out by this time. So, like, I’ll take this case, but I still have somewhere to be at 430. And so, you know, that’s crazy. But in those cases, like, as the resident responsible for that patient, for the case, you know, for the attending as well, because they’ve kind of given me, like, these limitations, I would just care so much and put so much weight onto making all those things work. So now imagine the or is running late or, like, a higher acuity trauma comes in and pushes us or something like that. It. It’s really hard to not put that, like, 100% seriousness on everything, but it’s just not a sustainable or healthy way to live. And so obviously, you know, we’re just talking because I guess my question would be, like, what is the balance? There obviously has to be a middle path. And I’m definitely, like, a believer that the middle path is a good idea.

Colin Royal: Yeah, well, and I think, too, like, probably should have said this earlier, but, you know, again, the idea is not to actually be middling, at everything, right? Like, you’re not trying to walk away from this and just be super mediocre. In reality, using this principle should actually result in higher performance. Right. So, like, by banging your head against the wall and going after the same thing over and over again. Yes, you will burn out. Right. But the way, like, okay, so a good example would be, you know, training, for a race, a marathon, or just like a five cave and. Right, so if you’re trying to run your best time, you’ve got this race coming up in a month. If you just run a literal five k every single day and you try to go as fast as you can, you probably get to a pretty good time. And then when you get to that race, you’re running your absolute maximum effort at 100%. You’re getting to the finish line, and someone’s about to pass you, you have nothing left in the tank. Right. Like, you’ve only practiced a five k. You have optimized to be in the 99th percentile of that five k. Someone’s passing you your toast. Right. So, like, the way to actually train for a race would be to mix it up, run different lengths. Right. In that finish line, you’re going to have to sprint a little bit. So practice sprints, run 400 meters. Right. Practice running a ten k, practice running 15 miles, and, you know, max out your speed at that, work on your longevity. That way, when you’re in the race, you only have to use about 90% of your energy. Right. You know, you can actually run faster. at a longer speed, you could run much longer than a five k. So you’re not just absolutely toast by the end of that race. And if someone is passing you at that finish line now, you have an extra 10%. Right. You’ve got that, like, next level to jump up and. And beat that person at race. And that’s kind of how you want to approach a lot of this stuff, right, where you need to try and recognize, like, where that level ends for a specific behavior skill and then see what the next one is. Start striving for that, basically.

Dr. Frances Mei Hardin: Yeah. And I think that the other thing that also makes this whole idea more palatable to me, like, you know, having kind of discussed this back and forth, it’s just that mediocre does not mean what you think it probably means or what I thought it meant coming into this, because it does not mean that, just, like, the care you provide is mediocre. And, like, patients think that, and, you know, like. And not just patients think that, but patients experience mediocre care. It’s just more that I get what you’re saying. You know, ENT is a small field, and not everybody in ENT nationally can be a 90th percentile at ENT. And so I think that it really just becomes, I mean, physicians put so much, like, pressure on ourselves to be excellent. Like, I don’t think anyone would just be hype to be under 90th percentile. I mean, some physicians I know wouldn’t accept themselves at under 99th percentile, but the reality is that the sample size just gets smaller and smaller, and there still has to be a distribution among them. And not only that, but I really like that running analogy. Just because diversifying the skillset, I can, you know, I could be convinced that that ultimately leads to a better, more excellent product or person.

Colin Royal: Yeah. Yeah.

There’s a balance between masking ability and giving your full effort

And I think the other natural question, like, we’ve danced around a little bit, but it’s like, how do you get away with this, right? Like, this seems sort of a risky behavior, and, like, eventually the charade will. Will be, you know, pulled away. Right. Someone’s just gonna say, hey, are you kind of sandbagging me this whole time? Like, what’s going on? I feel like you’re not giving me your full effort. Realistically, that’s probably not gonna happen very often, right? And if you think about it like, this is a pretty common thing that is happening all over the place, right? Like, a, very simple example is, you know, like a mom and child, you’re playing a game that mom could just wipe the floor, you know, with that kid. But they’re gonna kind of, you know, they’ll pretend like they’re trying hard, and then, oh, maybe they stumble, and the, you know, the little kid runs the race. The little kid is not gonna stop and say, hey, mom, what’s up? Like, I thought we were running this whole thing. Like, there’s sort of a give and take, there’s a balance, and then maybe in reverse, right? Like, the mom is telling the kid, hey, you got to clean your room every single day. The kid doesn’t clean his room. Everybody keeps it clean enough. That’s really what we’re trying to get, right? We just want a reasonably clean room. There is sort of this back and forth tug of, okay, I’m going to not give my full effort, but I’m also going to mask potentially, like, what my full ability is, right. Because if you actually do show in surgery, right, let’s say you’re. You are capable of doing in 16 hours surgery every single day. You’re like a superhuman, and you’re able to do that. They’re going to ask you to do that 16 hours surgery every single day. So, like, there has to be this kind of give and take. And, you know, realistically, no one probably would do that. But in, like, a worst case scenario, they might ask you to keep coming back. Or let’s say, like, you gained the reputation of always being at the hospital, right? You now know this resident. They’re always around. They’re always available to jump in. People are going to keep asking you to jump in, right? They’re going to ask you to fill in. They’re going to say, hey, do you want to get on this? It’s eventually just going to lead to you burning out. You’re never going to be home. You’re never going to be time. You have to be able to kind of mask your ability in some respects to based, upon really, like, the other party’s level of power, right? Because let’s say you are working with the chair of the department, and they’re asking you to do something specific well, that person might literally control your future, right? That might be the person who decides whether you’re getting fired. They’re going to give you the letter of recommendation. In that case, you might want to give almost your full effort for that, right? Still probably not 100%. Maybe you give 90% so that if you know the timing is right, you can once in a while drop in that 100%. And they say, wow, you know, oh, my God. The stuff I’ve been teaching them has been working. They are amazing. Like, I’m the best teacher. This is now my, you know, my star pupil. But if this is someone who, you know, to not have a lot of power within the department, and they’re constantly asking you for favors, you know, you can probably give 50% of your ability for that, and they are not really going to have the ability to get you in trouble for that. Right? And they probably know that. Right. They can’t threaten to fire you because they might have the ability to fire you. And if they do and they’re not able to follow through with that threat, now the whole charade’s broken, right? And now you can just totally sandbag because they’ve shown that they have no power and you’re good to go. So there is this, like, give and take that happens naturally. and it allows you to work at this mediocre level without having to look mediocre all the time.

Dr. Frances Mei Hardin: Well, I appreciate. I appreciate the discussion. I’m intrigued about the whole idea of capability masking. Obviously, as a surgeon, I could not possibly condone this or, endorse it, but I do think it’s interesting. Oh, my gosh. Okay, try to connect me again.

Colin Royal: Here’s a simple example, right? All doctors ask everyone, you got to be here 1530 minutes before your appointment. Everyone who goes to the doctors knows that it’s not going to start on time. So you’re both keeping up the charade of, you got to be here early, and then you’re going to start on time, and none of it happens, and it’s just accepted. Right. It’s like, well, obviously they’re not doing as much as they can, so maybe I’ll show up a little bit late. They’re probably not gonna kick me out. I’ve got about a 15 minutes window. there’s this understanding that, like, you don’t have to be absolutely optimal at everything. Maybe that helps.

Dr. Frances Mei Hardin: But should we try to be. Well, anyway, yeah, obviously, you know, everyone is going to have their own kind of experiences with this and opinions, but I do think that, like, there’s so much business strategy, workplace strategy, playing the game, how to approach all these things that, you know, has been mastered by a lot of people, like, even across the business world. And it’s definitely about time that physicians start to really look at it and utilize the principles that work for them. Like, that’s the whole point of the strategy episodes. It’s just to say, how do people excel at what they’re doing? Because there’s so much that is very much applicable to healthcare providers, really, like, at every level. So what?

Colin Royal: Hopefully, I’m a properly mediocre guest to discuss this thing with you.

Dr. Frances Mei Hardin: Oh, my gosh. Well, we’ll definitely, we enjoy doing the strategy episode. You know, we’re always open to any feedback or, questions. You know, if. If listeners have specific topics that they want, like, dissected, you know, strategized, then we’re always open to those, and so definitely let us know. We’ll keep coming back. Next week, we have Doctor Chelsea Churgen on the podcast to discuss her decision to leave her Ob GYN residency and how she created the life of her dreams. Follow me on Instagram at Francesmay, MD and residency. Visit my website, rethinkingresidency.com, to learn more about resident physician stories and ways that residents can most effectively navigate the game of residency. I cannot wait to connect with you on the next episode of Promising Young Surgeon.