The tightrope between fear and futility.

By: Daniel Cabrera


This post is a summary and commentary on Mihaly Csikszentmihalyi‘s (CHICK-sent-mee-hi) work on flow and its relation to education, particularly his book “Applications of Flow in Human Development and Education”.

I first heard of Csikszentmihalyi’s work while listening to Chris Hicks discuss stress inoculation. During the lecture,  Csikszentmihalyi’s  concept of flow focused on the setting of exceptional rendition under stressful circumstances.

Flow is described as the optimal psychological experience where consciousness becomes autotelic. In others words, it’s a mindset where the psychological state leads to ideal physical representation and performance. The original concept was focused on artistic creativity and the pursuit of happiness, but the core ideas have been transferred to other domains.

In terms of the application of flow to education, Csikszentmihalyi upholds the paradigm that learning/knowledge acquisition is and must be an enjoyable endeavor, which contrasts with his observation of the educational experience of many learners.  He believes the main issue is not a cognitive problem but an affective or motivational one. Simply put, learners who are not motivated enough to learn may find the process tedious and meaningless.

One of the key concepts of flow in education is the critical balance between a challenge and an impossible stretch goal. If the task is too difficult for the current set of skills anxiety results. If the challenge is too easy, the process is boring. The learners need to walk a fine line between anxiety/fear and boredom/futility in order to achieve optimal performance in learning.


This actually fits well with the principles of deliberate practice , where the repetitive practice of a task is incrementally increased in difficulty. Csikszentmihalyi believes that multiple emotions/psychological states can originate from the interaction between current state and an accepted challenge with flow the optimal state. The opposite to flow is either apathy (where the challenge is minimal) or anxiety (where the challenge is impossible).


The classic description of the necessary conditions for a flow experience are described below.


The main role of the teacher is to facilitate flow. It is important to make evident to the learners the raison-d’etre to learn a particular skill or concept. As important as a clear main goal are the creation of purposeful, actionable micro-goals serving the main goal. Feedback that is immediate and focused on the task is critical, avoiding ego-threats to the learners and self-consciousness.

Csikszentmihalyi believes teachers need to experience flow in their domain of expertise in order to facilitate flow in others. If a teacher does not exhibit motivation, he or she can’t imprint motivation.

Finally, the distinction between internal and  external motivation is important. External motivation, based on rewards outside of the process of knowledge acquisition (e.g., grades) is difficult to maintain. The main goal of the teacher is to create internally motivated learners, where the process of learning is as important (if not more) than the outcome, where the acquisition of information turns into an autotelic experience, achieving flow.

Sources and further reading

Image 1. Quinn Dombrowski. Flickr. CC BY SA 2.0.

Image 2. Original. Adapted from Mihaly Csikszentmihalyi.

Image 3. Oliverbeatson. Wikipedia. Public domain.


#KeyLIMEPodcast 117: When is a Resident Ready For Unsupervised Practice?

(Post)graduate medical education is evolving.  Duh!  Our current “ballistic” model is being replaced by a staged progression of independence.  Huh?  In other words: the current model (ballistic) restricts the autonomy of a resident, requiring close supervision right to the edge of residency.  Than, typically without warning, we launch the resident into unsupervised practice assuming that written exam scores are sufficient proxies for competence as an attending physician.  We hope that we launch them high enough (and for the vast majority we do) so that they can figure things out before they crash back to earth.

This week, the Key Literature in Medical Education Podcast tackles an alternative curriculum design – staged progression of ability (and autonomy).

Marie-Louis Stokes from the Royal Australian College of Physicians joins Anthony Llewellyn and Jason to discuss how the development of expertise occurs in pediatricians.

For more details, the abstract is below.

For all of the details, check out the podcast here. (Let’s all hope the Jason doesn’t adopt an embarrassing fake Aussi accent … )




KeyLIME Session 117 – Article under review:

New KeyLIME Podcast Episode Image

Li ST, Tancredi DJ, Schwartz A, Guillot AP, Burke AE, Trimm RF, Guralnick S, Mahan JD, Gifford KA; Association of Pediatric Program Directors (APPD) Longitudinal Educational Assessment Research Network (LEARN) Validity of Resident Self-Assessment Group. Competent for Unsupervised Practice: Use of Pediatric Residency Training Milestones to Assess Readiness.  Academic Medicine. 2016 Jul 26. [Epub ahead of print]

Reviewer: Marie-Louise Stokes (@marie_stokes)


Since 1 July 2013, the ACGME in the US requires evaluation of trainees (residents) using Educational Milestones (observable developmental levels of behaviour) mapped to their 6 competency domains:

  • Patient Care
  • Medical Knowledge
  • Interpersonal and communication skills
  • Practice based learning and improvement
  • Professionalism
  • Systems Based Practice

The milestones are organized across 5 levels from beginner to expert–

The Pediatric group has defined their milestones using the Dreyfus model of expertise development

Level 1 – novice (early medical student)

Level 2 – advanced beginner

Level 3  -competent

Level 4 – proficient

Level 5 – master (seasoned expert practitioner)

The ACGME set a target (not a requirement) for achievement at graduation at level 4

Pediatric group developed milestone descriptors for their 21 subcompetencies that sit across the 6 domains.

The Pediatric Group have not yet defined their explicit benchmarks for assessment; they wanted to use empirical evidence as the basis for setting milestone achievements for pediatric trainees across pediatric programs.


To describe clinical skills progression during pediatric residency by analyzing the distribution of milestone assessments by subcompetency and year of training (PGY1, PGY2 and PGY3) to determine reasonable m\milestone expectations at time of graduation.

Type of Paper

Research: Cohort study (prospective; multi-institutional)

Key Points on Methods

Multi-institutional prospective cohort study

47 of the 199 US (24%) paediatric programs participated covering 2030 paediatric residents. Participating and non-participating programs and residents were comparable on a range of demographic variables.

Descriptive statistics –for  subcompetency milestone ratings by year of training.

Key Outcomes

Fewer than 21% of residents achieved a 4 (proficient) or higher in all 21 subcompetencies

Most residents (79%) achieved a 3 (competent) or higher in all 21 sub-competencies.

Overall the study group of residents combined (using mean as the measure) progressed in their milestone ratings across the 3 years of training.

Found that variation in milestone rating was greater in PGY1 than PGY3.

There appears to be less grade inflation using milestones than the traditional 5 point Likert scale.

Key Conclusions

 The authors conclude…

  • Trainees enter training with a wide range of skills but as they advanced skill variability decreased
  • Most graduating pediatric residents were still advancing on the milestone continuum towards proficiency and mastery and
  • An expectation of level 4 or above in all categories is unrealistic
  • An expectation of level 3 or more is more realistic
  • Milestone data can be used to identify key areas that should be specifically targeted during training.

Spare Keys – other take home points for clinician educator

The importance of using empirical evidence /data to guide and validate important policy decisions like what the required levels of achievement for graduating trainees.

The great opportunity to use these types of data to enable trainees and programs to benchmark themselves against peers and identify areas of strength and areas for improvements.

Shout out

Commend the LEARN group for doing the study.

Listen to the podcast here

Pause for Thought . . .  ‘Kids these days!’

By Lynfa Stroud

“When I was a resident ….” – Almost every faculty who ever lived


It’s a refrain that I hear from faculty from time-to-time. It’s essentially the physician’s version of, “the good old days” or “kids these days”.  It is usually the start to a discussion about how something was done better in the past – either with respect to individual resident performance or to the structure of education / clinical training; but occasionally it does connote recognition that things have changed for the better. As the new group of residents excitedly started their academic year in July, it made me reflect on some of the changes that have happened in the relatively short time since I was a resident.  Most of these have undoubtedly been improvements, but have also had some unintended consequences that have led to other challenges in other areas and challenge us to continually evolve.

To pick three random areas where there have been significant changes that, while largely better for either patient care or resident wellbeing (and sometimes both), may have also had unintended consequences, I would select some of the changes that have occurred with work hours, care models, and technology.  For this post, I’ll briefly muse about the change in work hours, and then in a subsequent post I’ll follow-up with thoughts about care models and technology.

Fairly progressive and reasonable duty hour limits existed when I trained. But they were rarely adhered to. It was typical to stay post-call to finish working the entire day. One of my surgical colleagues was scheduled for 72 hours of straight call – though not on paper where this could be scrutinized. Changes in duty hours and closer adherence to them has undoubtedly improved resident wellbeing and is entirely appropriate (there’s a lot of arrogance in thinking your performance is as good after being up for over 24 hours as it is when rested). Of course, I am sure that adherence is not 100% and that many residents still work beyond what they are meant to, but I like to think less egregiously than in the past.

This shift though has had other knock-on effects though, such as potentially less continuity of care and a greater reliance on faculty to provide patient care.  Neither of these is a necessarily a bad thing, but have relied for us to consider their implications and possible ways to mitigate their impact. For example, there is now much greater attention to sign-over than there ever was when I trained – and residents are actually taught how to do this! Faculty may have to adjust their commitment to other activities to be more directly involved on the front-lines of patient care, which certainly can be argued to have many benefits, although alternatively can have the unintended consequences of diminishing faculty’s time for other activities or reduce the autonomy of residents in decision making.  Other possible solutions to ensure the provision of clinical care could include re-allocation of resident staffing or the use of physician-extenders. However both of these in-turn also have potential pros and cons, with the latter being taking residents away from one activity to another and the cost incurred from hiring other professionals.

I would not want to return to the adherence (or lack thereof) to duty hours when I was a resident, or even worse the hours endured by those of prior generations. However, in making this improvement, we’ve been challenged as a profession to ensure that we manage the outcomes and, in particular as educators, to mitigate the unintended negative consequences for learners with new curricula.

ICE Book Review: Essentialism – The Disciplined Pursuit of Less

51mnb2f9xwlBy Rob Cooney

“When everything is a priority, nothing is a priority.”

-Simon Fulleringer

Do you feel overwhelmed? Do you have too much to do in too little time? These days, many of us will answer “yes” to the above questions. The essentialist doesn’t agree. The essentialist acknowledges that we can’t have it all or do it all. Unfortunately, this is easier said than done. Many of us fall into a trap.

We work hard and earn success. Our success earns us more opportunities. People seek our help or offer us exciting projects. As we say yes to these opportunities, we spread ourselves thin and become less effective at accomplishing what we desire. Our success undermines our future success.

To reverse this phenomenon, Greg McKeown explores the idea of the “disciplined pursuit of less.” To do this, he breaks essentialism into these main components:

Do less, but better

This is the “essence” of essentialism. McKeown argues that it isn’t simply learning to say “no” more often, it’s about “…pausing constantly to ask, ‘Am I investing in the right activities.’” As we all acknowledge when forced, there isn’t enough time to pursue all possible exciting opportunities. We must choose.

“Keep in mind that you are always saying ‘no’ to something.”

-Steven R. Covey

Reject the notion that we should accomplish everything

Success requires elimination. There is a profound amount of “noise” in our lives. Essentialists filter out the noise with a simple word: No. Unfortunately, accomplishing the “no” isn’t simple. It requires the essentialist to push against social expectations and can be frightening, but it is critical to success.

Remove obstacles to make execution effortless

Execution often seems to take a lot of time and energy. Essentialists deliberately design systems that make execution easier. Execution can be accomplished by building buffers, eliminating constraints, and focusing on small wins.

Essentialism as a concept is so simple it seems common sense. It runs counter to other productivity hacks because  the key to success isn’t getting “more” things done, but focusing on doing less in order to get the “right” thing done. We would all benefit from applying the concept to our “too busy, have to get xyz done” lives.

#KeyLIMEPodcast 116: When is a clerkship not a clerkship

The Key Literature in Medical Education podcast turns its attention to undergraduate medical education (i.e. medical school) this week.  Think about your own clerkship.  Did you rotate every 4 weeks to a new service – medicine, pediatrics, psychiatry – spending the first half of the rotation simply trying to figure out the culture and how not to embarrass yourself?  Maybe there’s a better way?  In fact, this debate around discrete rotations versus longitudinal rotations is the topic of a debate I will be moderating at the International Conference on Residency Education, Saturday Oct 1.  Check back here the week of September 26 for details on how you can stream the debate live or find details at #ICRE2016.

Back to the podcast… the idea of a longitudinal clerkship has appeal.  A medical student follows a cohort of patients through all of the ins-and-outs of the healthcare system, gaining an integrated appreciation for how all the parts work.  However, there are likely some operational / design features that such an idealist design fails to appreciate.  The podcast this week looks at the typology (i.e., cardinal features) of a longitudinal clerkship.

Find the full podcast here.

The abstract is below.



KeyLIME Session 116 – Article under review:

New KeyLIME Podcast Episode Image

Worley P, Couper I, Strasser R, Graves L, Cummings B-A, Woodman R, Stagg S, Hirsh D and the Consortium of Longitudinal Integrated Clerkships (CLIC). A typology of longitudinal integrated clerkships.  Medical Education. 2016. [epub ahead of print]

Reviewer: Linda Snell (@LindaSMedEd)


Longitudinal integrated clerkships (LICs) are a relatively new approach to clinical education for senior medical students:  shaped by continuity, extended education experiences, and long relationships between students, patients and physicians (teachers). Thought to be more ‘authentic’ with extended immersion and students’ meaningful contribution to care and thus perhaps encourage students to choose careers in underserved contexts.

These programs are burgeoning: 17 in 2009 to 48 in 2013 in US, Canada, Australia, and South Africa.

However the definition and characteristics of an LIC are variable and contentious. A consortium of LIC schools (CLIC) proposed a consensus description using the elements of longer time than usual block rotation, ongoing relationships (clinical and learning), and incorporating experiences in multiple disciplines to meet most of the academic core competencies. In most of these the student follows the patient through multiple contexts of care.


‘to establish a baseline reference typology to inform further research’

Type of Paper

Research: Delphi, survey

Consensus paper

Key Points on Methods

CLIC formed research subgroup (methodology design group – MDG)

  1. Delphi process of all CLIC members to develop survey items
  2. Survey – via online, phone or Skype interview or FtF

(demographic: # & gender of students and % of total class, # & size community, rural, length of LIC, proportion of academic year and where situated in medical curriculum, who teaches/supervises, # disciplines)

Analysis: standard stats, univariate and ANOVA, cluster analysis and a ‘qualitative review of results focused on length, proportion of academic year and # disciplines taught’

Showed results on a world map to provide a visual representation.

Iterative discussion of results with CLIC.

Key Outcomes

54 programs from 44 schools (6 schools had >1 models) with 15,000 student-years represented.

All met criteria of ‘comprehensive care over time’ and ‘continuing learning relationships’. BUT length of LIC varied from 6-54 weeks, with 2/3 being full year.

Typology based on:

-3 distinct types of LICs identified – according to length & discipline coverage:

  1. amalgamated: shorter clerkships that combine learning in a # of disciplines, but not the ‘majority’ of curricular content or time [the authors propose that these not be called LICs]
  2. blended: incorporate majority of disciplines but use complementary discipline-specific rotations to complete academic year
  3. comprehensive: all disciplines incorporated delivered as an integrated program (very few discipline-specific)

-2 contexts programs based in:

  1. general practice/family medicine, usually in ambulatory settings in smaller communities with FPs/GPs as supervisors
  2. urban settings, hospitals and clinics where subspecialists more likely to supervise

The type varies according to geography – more likely to be integrated in N America, and with longer standing programs

A minority of schools have >1 type – up to 4

Key Conclusions

The authors think they have demonstrated ’the common elements and diversity’ of LICs. They propose a series of excellent research questions. As many programs share core characteristics, it allows study across schools to increase power and generalizability.

Spare Keys – other take home points for clinician educator

Note the ability of consortia to generate research ideas then have the human and other resources as well as the power to obtain meaningful results, and further to use the results to generate research questions

Authors note varying language to describe same phenomenon in different countries, so interviews useful for clarification (see Cantillon et al ‘Lost in Translation’, Med Ed 2009)

Shout out

Strasser, Graves, Cummings.

Listen to the podcast here