I recently heard a short talk by Eduardo Briceño that got me thinking about the content of this post. He talked about learning and performance zones. I think preparation is a better word than learning to describe this pre and post performance phase. Preparation encompasses more than learning and I like two Ps. They remind me of a life-changing principle I learned from my principal while in grade school.

“Proper Preparation Prevents Poor Performance.” That’s the principle of the 5 Ps.

I also like to see this phenomenon as modes of thinking, mindsets or paradigms, rather than zones in which we operate. So I prefer the preparation mode and performance mode.

Why do some people tend to succeed at what they do when others don’t? Is it because those who succeed are smarter? Is it because those who succeed have more charisma, passion, character, luck, etc?

I don’t think it’s any of those things.

Like Briceño, I think those who are less successful focus more and spend more time in the performance mode while those who succeed are always dancing between preparation and performance. Those who succeed take preparation as seriously as performance, if not more.

Take the example of medicine. Residents are bombarded with a lot of work. Sometimes they have to work up to eighty hours per week. Many residents get overwhelmed with the workload and the acuity of the sick patients that they only think about getting the work done (performance).

The focus on getting the job done is good and is often supported by senior physicians who see the residents who speedily complete tasks as better team players.

Simultaneously doing preparation and performance on every single case can initially slow down the few residents who choose to do so since these doctors are learning from every case as they go. The patient in front of them is important and deserves their 100% attention. However, they don’t simply focus on getting the job done or performing with the knowledge they have at hand. That would be performance. They focus on understanding the patient’s disease process thoroughly–stopping to learn if they need to–before performing tasks. They don’t just want to do something to the patient because they were told. They want to understand why it is good for that patient. This understanding helps them reduce errors that might be propagated through the chain of command from attending physician to the patient. Obviously, this kind of preparation and learning mindset can slow things down a little, initially. But it’s good for the patient being seen now and certainly for future patients.

The doctor who prepares to be the best she can be is doing a public service, not a selfish or personal act.

I’ve heard some people want to separate the preparation or learning time from the performance time. They say such things as, “Focus on getting all the work done and when you go home in the evening, you can read about the cases you saw during the day.” The motives are very good. However, people who try to procrastinate like that realize that it doesn’t usually work as hoped. First, by the time you get home, you are very tired. You may forget, etc.

Every successful person I know who juggles both modes at the same time must continue to learning at home and on their free-time. I know people who read about their hospital patients when they are not on shift and when they come back, they make changes to improve the patient care. Sometimes, I’ve seen such people call in the middle of the night because they saw a lab result they had ordered and had read more about the case and knew something better to do that perhaps the physician currently on the case didn’t know or think about. So learning always must continue later on. One cannot do all their learning while seeing patients.

Delaying this learning also delays interventions that might me made to impact the patient immediately if learning were ongoing and not kept for later. Rarely, I’ve seen a resident protect a patient from harm because she didn’t understand something she was asked to do to the patient by someone senior. She stopped for a few minutes and looked it up, showed the senior doctor why the information provided wasn’t accurate and change was made that protected the patient. This kind of learning doesn’t take too much time. It may add ten minutes to the care of one patient initially. It may make a day longer by two hours–initially. But it gets faster as the resident or doctor becomes really good at juggling preparation with performance on every single patient.

I don’t think of myself as a particularly smart guy. One thing that I do know and have been commended for over and over again is my drive to learn. I actually love to learn, not just for the sake of learning but because I see what preparation can do to those I serve, now and in the future. I love to learn so much I have taken many courses on the learning theory–all of them just for my own edification. I am always learning how to learn.

Recently, I have seen significant success on my job. After leaving my heavily knowledge and experience based line of work and running an orphanage for nearly five years, I came back and picked up quickly. Let me illustrate what I mean by quickly.

Early July after I came back to work –after nearly five years of absence—I am given an exam. I fail so miserably, I was the last in my class by far. In October, I take another exam that compares me with my peers again and only there months later, I rose to the top. A year later I am tested with my peers and I ran highest by a large margin.

It’s not just exam scores, many of my supervisors are very impressed with my practical skills.,

Within one year from returning, I am doing better than I was doing before I quit my job before. Yet I am almost 40 years old and have a wife and two kids. [I must say far from being a distraction, these three are so good, they actually help me do better].

Some have said I am a good test taker. That I do well on standardized tests like the ones we must take yearly. I laugh at the thought of that. One only has to go back and look at my MCAT, USMLE step 1, 2, and 3, and my 2009 ITE scores to realize that that assertion is far from the truth.

Something has changed, and I am very pleasantly surprised by it. I am amazed at the rate at which I have come back and actually exceeded my expectations.

I like to reflect on my failures and successes to find ways to learn from them. I think there is a growth mindset that a person must have to live between the preparation and performance phase. This kind of growth mindset enables one to be a perpetual learner, to believe that they are able to overcome even challenges that have held them down for many years.

For me, I’ve dedicated a lot of time over the last one and a half year learning how to read. Yes, that’s right, how to read. I felt that one of the things that have held me down was because I was such a slow reader. I’ve had this problem for a long time and worked on it before. But this time, I gave it my best shot knowing that I can improve myself. For example, my recent exam was the first time on a standardized test that I actually finished the exam on time without rushing to blindly choose answers so that I don’t leave a portion of the exam blind. Both knowledge and practice on pacing myself were helpful. And this victory is not limited to the exam, it helps me in everything else that I do. If I can pace myself to read a little bit faster without losing comprehension, it helps me as a doctor in practice because we are required to read a lot of material.

Two junior colleagues at different times during the last month have asked me in a serious fashion, with obvious intention to learn, what my secrets to success were on the job.

I’m NOT the smartest guy in the organization I work for. I’ve improved so much because I have developed a growth mindset and religiously treat preparation and performance as equally important and do them at the same time. I ask more questions, which unfortunately sometimes slow me down, but I think that is in the best interest of my patients present and future that I do that. As time has passed, I have gotten faster at doing both at the same time.

I think you perform best when you are learning even as you perform.

In a sense, the quality of care must come before the quantity of care. Balancing preparation and performances addresses both.

Want to listen to Eduardo Briceño’s talk?