“Our specialty is not specializing”

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Having recently turned in my first-year summative portfolio (what we do at the Cleveland Clinic Lerner College of Medicine [CCLCM] in lieu of exams and grades), I can’t help but reflect on how this unique system of evaluation has changed my outlook and afforded me tremendous growth during this first year of medical school. “No exams and no grades?,” people often remark when I explain our curriculum, “Sounds like a pretty sweet deal!” While the true ways in which this system is “pretty sweet” may not be so apparent on the surface, they are many-fold and offer insight into what may be a much more fulfilling approach to life (once the initial discomfort is accepted, of course).

From a very young age, I, like many others, have been conditioned to strive for perfection. Whether in school trying to please teachers and earn perfect grades or at gymnastics practice performing movements over and over again so that my routines might score just a tenth of a point closer to a “perfect 10,” I always focused on the most minute details to be sure that I gave my best effort in every endeavor. I thought that as long as I studied hard enough or practiced long enough, “perfection” would be within my grasp. While this approach did me well in the sheltered environment of my primary school years, once set loose into the real world and exposed to the vastness of knowledge and possibility, I quickly realized I had neither the time nor the energy to embark upon such a comprehensive quest for perfection in each avenue I wanted to explore. Because in college grades provided the single most visible measure of my abilities, I began to channel my perfectionist tendencies toward my transcript. Trying to hang on to the possibility of perfection by dedicating myself to this single endeavor with such an important outcome, I would often find myself settling for a less-than-perfect effort in other areas such as extra-curricular activities or spending time with friends and family. As each semester passed and the amount of information to learn and assignments to complete continued to grow exponentially, I also found myself losing touch with the pleasure of learning for the sake of learning and sometimes even sacrificing my own true understanding of material in pursuit of perfect grades. However, these grades provided a false sense of satisfaction – though I walked away from many an exam feeling confused and defeated, upon receiving a grade I considered satisfactory I never again considered returning to my books to clear up my previous qualms – I was too busy studying for the next exam to earn the next grade. Perhaps these grades, in addition to disproportionally shifting my efforts toward only one aspect of my life, masked many of my weaknesses and hindered me from making further improvements.

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What’s in a grade, anyway?

Enter medical school: no grades, no exams, and the analogy “drinking water from a fire hose” could not be more true. The amount of information to learn, shadowing and volunteer experiences to be had, and research projects to conjure up seemed endless from day one. Students who have been conditioned to strive for perfection their entire lives are suddenly overwhelmed with the impossibility of learning it all, and gone is the opportunity to feel even a slight sense of validation for our efforts by earning an “A” on an exam. However do these type-A’s cope with such a situation? From my experience, the answer lies in gaining comfort with recognizing and unmasking our weaknesses and in acceptance that balance across many domains trumps perfection in just one – a.k.a, the portfolio system.

Instead of the traditional system of exams and grades, the CCLCM implements a portfolio system in which students evaluate their own progress in 9 separate competencies: research, medical knowledge, communication, professionalism, clinical skills, clinical reasoning, personal development, health care systems, and reflective practice. Incorporating feedback provided by faculty and peers throughout the year, we assess our progress toward achieving the standards in each of these competencies and devise realistic strategies for making improvements.

In the above description, you will notice that medical knowledge provides only ONE of the 9 competencies in which we are assessed. The portfolio system recognizes the equal importance of each of these areas in the development of physician researchers and does not allow us as students to neglect any one in exchange for deeper pursuit of another. Sound familiar? CrossFit also recognizes that in order to achieve optimum physical competence, one’s ability must be distributed evenly among “10 General Physical Skills” – cardiovascular endurance, stamina, strength, flexibility, power, speed, coordination, agility, balance, and accuracy. We concede that as CrossFitters we may not achieve the level of stamina displayed by an Olympic triathlete or the strength of a world-class powerlifter, but we are willing to make those sacrifices in order to maintain balanced physical abilities. In much the same way, as physician-researchers-in-training, we recognize that we may not have the degree of knowledge in any given subject area as a Ph.D. researcher or the understanding of health care systems of health policy makers, but we are willing to sacrifice striving for such a degree of perfection in any one of these areas in order to be competent in the many areas that allow us to successfully care for patients and improve the field of medicine. For individuals conditioned to strive for perfection, this is not an easy task at first – it requires us to step back and evaluate our goals.

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The CCLCM portfolio system and CrossFit – recognizing that balance across many areas may be better than perfection in just one

Could I be better at Olympic lifting? Yes, probably, if I spent all of my time practicing Olympic lifting. But what is my goal? My goal is to achieve optimum physical competence, therefore I cannot afford to spend all of my time practicing Olympic lifting while neglecting development of other areas such as endurance and stamina.

Could I achieve greater breadth and depth of medical knowledge? Absolutely, if I spent all of my time pouring over my textbooks and memorizing every word. But what is my goal? My goal is to become an excellent physician researcher, so my medical knowledge will be useless if I have not also developed skills such as communicating with patients and clinical reasoning.

Additionally, you will notice in the description of the portfolio system that gone are the days where our shortcomings can be hidden behind the outcome of a stellar grade. In this system the façade is removed and we are all forced to address our weaknesses. We are required, even rewarded, for identifying the areas in which we need to make improvements and then acting on them. This notion is one that society frequently shies away from. Constantly pressuring individuals to exude an air of perfection, society persuades us that the perfect outfit or a stellar college transcript, house, or career can provide a façade for the imperfections and insecurities that we all have. While they may allow us to proceed through life smiling on the outside, outward expressions of perfection may actually prevent us from recognizing our flaws and capitalizing on real opportunities for growth. In a similar way to the CCLCM portfolio system, CrossFit also acts to eliminate façades of perfection, giving individuals the opportunity to be vulnerable, to explore their weaknesses, and to learn from them in order to become better athletes all-around. The beauty of CrossFit is that it cannot be bested by our fancy façades – no matter who you are, how much money you make, or what kind of clothes you are wearing, CrossFit will force you to come face-to-face with your imperfections. In so doing, CrossFit allows us to conquer these weaknesses that we otherwise might have shrugged off, avoided, or kept hidden to ourselves. By calling our bluff – exposing weaknesses in the gym and showing us that it is possible to make improvements, CrossFit empowers us to extend this behavior to other aspects of our life. And though we may feel vulnerable at first, identifying, rather than ignoring, our shortcomings and taking steps to overcome them paves the way for an exponentially more fulfilling life.

My first year at the CCLCM has reinforced the concepts that CrossFit teaches me every day. The portfolio system reminds me that “perfection” in life is defined by our own personal goals, and sometimes balance across  many competencies IS the perfection we strive for. As our goals shift, so does this “perfect” target, such that we are in constant pursuit of betterment. Additionally, I am assured that though incredibly uncomfortable, true growth is possible only by stepping out from behind our façades of perfection to grapple with our weaknesses. In doing so, we gain strength in our shared struggles and the impetus to work toward the goal of becoming better human beings.

“Our strength grows out of our weaknesses” ~ Ralph Waldo Emerson