Grit, the perseverance and passion for long-term goals, is a key personality trait linked to high attainment in many fields. In medicine, it has been associated with several desirable characteristics of good doctors, such that some institutions are now including grittiness in the selection criteria for medical school and surgical residency candidates.
A closer examination, however, reveals that grit may not be the magical potion it is lauded to be. Although grit is positively associated with stamina, commitment, and perseverance, when applied indiscriminately, it can be transformed into Machiavellian traits such as narcissism and a disregard for ethical values. Rather than simply selecting gritty candidates, we should work to create a culture of surgical training that supports, nurtures, and enhances grit within our surgical trainees to mitigate unacceptable levels of burnout in the medical profession.
WHAT IS GRIT AND WHY IS IT IMPORTANT?
Grit can be defined as perseverance and passion for long-term goals, and the tenacious pursuit of a dominant superordinate goal despite setbacks.1 It is an adaptive personality trait associated with desirable attributes, including being hard-working, remaining committed despite setbacks, and stamina. It has been shown to correlate with success in many fields, such as educational attainment, military training, and even ranking in the U.S. National Spelling Bee.1
First referenced as a character trait in 1863 by Nathaniel Hawthorne (author of The Scarlet Letter), grit has been mentioned in educational discourse as far back as 1909, when Edward Lyttleton, the then-headmaster of the prestigious Eton School, bemoaned the lack of it in his students.2 Despite not being a new concept, grit has recently experienced a resurgence in popularity—in part, promoted by Angela Duckworth, a psychologist at the University of Pennsylvania, who has done much to bring the topic of grit to modern management theory, including presenting a TED Talk on grit on the video streaming platform YouTube.3 Duckworth tells us that grit has little correlation with intelligence but is a strong predictor of high achievement, most notably in grade-point averages and for which students persist into university.3
THE GOOD, GRITTY SURGEON
Grit is not just relevant in education or business psychology; it is also becoming recognized in many subspecialties within the field of medicine. Recent research has shown that grit is associated with certain personality traits viewed as desirable for doctors: empathy, self-control, less aggression, and lower hostility.4 There have even been calls for grittiness to be included in the selection of medical students or surgical residents to ensure institutions are recruiting the right type of students to enter training.5
Applied to surgery in particular, grit seems to play a key role. Pulos and Shin cite P. W. Brown’s historic 1987 article, “Less Than Ten: Surgeons with Amputated Fingers,” which notes that, of 183 surgeons who had lost parts of their hands ranging from a fingertip to the entire hand, only three claimed any significant professional disability. All others were able to operate with some modifications. Brown concluded that patient motivation is the most important factor in hand function, rather than the injury itself. This motivation could also be characterized as grit. Pulos and Shin emphasize Sir Sydney Sunderland, one of the most renowned nerve surgeons, as a famous, gritty, partial hand amputee who did not let his disability stop him laying the foundations for the field of nerve surgery.6
Able-bodied surgeons also credit personal grittiness as integral to surgical career success. For example, the president of the Southern Association for Vascular Surgery, Gilbert Upchurch, used his presidential address at the society’s annual meeting in 2021 to credit grittiness as an important reason for his and others’ career successes.7 Another recent example comes from Andrea Hayes, chief of pediatric surgery at the University of North Carolina School of Medicine, who credits grit in the success experienced by her and other female surgeons and surgeons of color:
All of us, as surgeons, have grit, or we wouldn’t be here. But the idea of grit takes on a different meaning when you are female or African American or both … if a colleague who is female or a person of color seems a little more determined, a little more resilient, a little grittier, it’s because they have to be.8
It is not just doctors (and medical students) who benefit from grit; there is also an association between patient self-reported grit and adherence to medical treatment. In a recent study of patients with type 2 diabetes, personal grittiness was associated with greater treatment adherence and better glycemic and cholesterol control.9 Grittiness is, therefore, an important trait in health care, both for doctors and for patients.
THE BAD, GRITTY SURGEON
We defined grit as the tenacious pursuit of a determined goal despite setbacks. What if this goes too far? Grit is also associated with certain negative personality traits, such as Machiavellianism, perfectionism, narcissism, and a disregard for ethical values.10,11 We could think of grit more simply as having a high threshold for changing strategy (e.g., when Winston Churchill said, “Never give in, never give in, never, never, never, never—in nothing, great or small, large or petty—never give in except to convictions of honor and good sense”).12 People who score 1 SD above average on grit were found to be 35 percent less likely to change jobs; however, if a company is foundering or badly managed, jumping ship might be smart. Who is grittier, the immigrants who strike out for new opportunities, or their peers who stick it out in their home country?12 The dark side of grit is a surgeon who is rigid, who cannot admit when he or she is wrong, or who cannot accept suggestions from others. Gritty surgeons may not know when to stop; could they push patients toward treatments when it is not in the patients’ best interests? After all, the old adage goes: “Good surgeons know how to operate, better ones when to operate, and the best when not to operate.”
HOW CAN WE HARNESS GRIT?
Surgery is a tough career that requires great personal sacrifice and, at times, personal hardship. In the end, we want gritty doctors who persevere and have a sense of purpose, but we also want them to have the right motivation driving that determination.
Although the concept of grit has existed for more than 100 years, we have yet to fully understand it. Educators and psychologists continue to ask questions to push our understanding of grit. For instance, can grittiness change? We know a child’s personality becomes more stable as he or she progresses through key developmental stages; research on adults suggests that personality traits may actually change over a lifetime.13 Second, how do emotions impact grit? We know emotion and cognition work together to help us persevere on a task. Grit enhances self-discipline and self-control, both of which enable us to govern our emotions and thoughts. Are gritty students—particularly when pressured by parents, teachers, or even patients—dealing with their emotions appropriately?13 Furthermore, how exactly do we measure grit, and how do we discriminate it from similar personality traits such as conscientiousness and self-control? Our most popular measurement tools are Duckworth’s 12-point Grit-O scale and its shortened companion, the eight-point Grit-S scale, both of which measure perseverance of effort and consistency of interest in a self-reported format.14,15 These scales have received mixed external validation in the academic literature but are widely used in the global popular press.16 Population-specific versions also exist, such as the Grit Scale for Children,15 and domain-specific versions such as the Academic Grit Scale.17
A recent study evaluating the association of grit with burnout from a cohort of residents sitting in the 2018 American Board of Surgery examinations found that residents with higher grit scores were 47 percent less susceptible to burnout, 39 percent less likely to have thoughts of quitting, and 42 percent less likely to report suicidal ideation.5 If we can learn how to measure and improve personal grittiness, whether it is through enhancing well-being or otherwise, could we begin to screen our students for grittiness? Not as a yardstick, but as a starting point for improvement? If students are found to be “un-gritty,” could we enroll them in a grit-improvement course before beginning their grueling and prolonged career choice?
Data on grit in surgical training have so far been merely correlational, not causational. We do not yet have evidence that selecting residents with high levels of grit will result in lower levels of burnout. Furthermore, there is no convincing evidence that interventions to enhance grit will decrease burnout.5 In their article for the American College of Surgeons Division of Education, Han and Salles propose that, instead of the relationship between grit, well-being, and burnout being seen as unidirectional (whereby high levels of grit lead to improved well-being), we should reverse our mentality to focus on improving well-being to promote grit.18 Perhaps we can take Han and Salles’ idea further to propose a circular system wherein grit and well-being are complementary states, each positively reinforcing the other.
Instead of selecting residents based on their amount of innate grit and penalizing aspiring surgeons who were not lucky enough to be born gritty, perhaps we could help some achieve greater levels of grittiness. How do we create a culture of surgical training that supports and nurtures grit within our surgical trainees? Han and Salles and Loftus et al. suggest some methods.18,19
We need to improve work culture by giving our trainees the autonomy they seek, but also mentorship when they need us. We should recognize and reward their hard work regularly. We should foster an environment of open communication and transparency with timely and meaningful feedback.
We need to improve the work environment by providing affordable healthy food around the clock, establishing high-quality on-call rooms with dedicated computers and easy access to physical and mental health services, including protected time off for doctors’ appointments. We need to increase meaning in work through setting meaningful goals and serving a higher purpose. Trainees who see their work as a calling rather than merely a job to pay the bills or which brings social prestige are known to be more satisfied with work and life in general.20 In surgery, we need to remind trainees of the reason they chose medicine as a career by ensuring a fair balance of training and service commitments, such as restricting junior doctors’ time spent in purely administrative roles.
We should acknowledge individual limits, accepting that each trainee is unique and will possess different levels of grit. Training programs should work to provide individualized support rather than a one-size-fits-all module.
We should maintain balanced positivity. Levels of positivity can be understood as a ratio of positivity to negativity, and research has shown that a ratio of three to six parts positivity to one part negativity is optimal. To improve a low ratio, trainees should be encouraged to reframe negative events in a positive light; for example, viewing failures as opportunities for learning.
We should engage in deliberate practice. Surgical skill is built through persistent, high-quality, and deliberate practice, as described by Gladwell’s 10,000-hour rule, which states that if one practices a skill for 10,000 hours, he or she will have a good chance at becoming an expert at it.21
We should persist in hard work, valuing effort more than talent. Data have shown that, although some degree of talent is necessary, success depends more on hard work. Duckworth has proposed a formula whereby, when it comes to achieving a goal, effort (grit) is twice as important as talent1:
Grit can be defined by the acronym growth, resilience, intensity, and tenacity.14 It is seen by some as the latest much-hyped ingredient of personal success. Associated with stamina and commitment, institutions are actively incorporating grittiness in the selection process for medical school and surgical residency. Gritty patients have also been shown to better adhere to treatment regimens. Data on grit in surgical training are so far associative only, and there is no strong evidence yet that interventions to enhance grit decrease burnout. Strategies to improve well-being may be more effective than prevention and treatment of burnout. Rather than simply selecting gritty students, we should strive to change our culture to lower the unacceptable levels of burnout in surgery.
1. Duckworth AL. Grit: The Power of Passion and Perseverance. First Scribner hardcover edition. New York: Scribner; 2016.
2. Ris EW. Grit: A short history of a useful concept. J Educ Controversy. 2015;10:Article 3.
3. Duckworth AL. True grit: Can perseverance be taught? TEDx Talks October 18, 2009. Available at: https://www.youtube.com/watch?v=qaeFnxSfSC4&t=341s
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5. Lipsett PA. Grit among US surgical residents: Food for thought. JAMA Surg. 2021;156:864.
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7. Upchurch GR Jr. Grit matters in vascular surgery. J Vasc Surg. 2021;73:1477–1484.
8. Hayes AA. 2021 Olga M. Jonasson lecture: Grit in spite of adversity—In the pursuit of excellence. Available at: https://www.acsccnews.org/jonasson-lecturer-to-examine-true-nature-of-grit-for-women-people-of-color-in-surgery/
. Accessed November 2, 2021.
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12. Posner N. There’s grit, and there’s true grit. The New Rambler, July 25, 2016. Available at: https://newramblerreview.com/book-reviews/psychology/there-s-grit-and-then-there-s-true-grit
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18. Han B, Salles A. How the personal characteristics of grit and resilience relate to surgeon well-being. American College of Surgeons: Resources in Surgical Education website. Available at: https://www.facs.org/education/division-of-education/publications/rise/articles/grit-resilience
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21. Gladwell M. Outliers: The Story of Success. London: Allen Lane; 2008.