I write this piece on the day of the final hard “workout” of a marathon training cycle, but the ideas below apply to any goal-oriented individual, which we can all agree describes most cardiothoracic surgeons. The concept is how to think about “process-oriented goals.”
Educators, psychologists, and athletes categorize goals into three types: process, performance, and outcome. Process-oriented goals refer specifically to executable steps of a plan—for example, to read journal articles or work on academic writing for one hour a day. These are generally considered 100% controllable by the individual. Performance goals are based on some personal standard—for example, to generate a certain number of RVUs or publish a minimum number of manuscripts. Performance goals are mostly controllable, but likely less so than process goals. Finally, outcome-based goals are purely based on a result—for example, receiving a high-level government-funded grant or landing a chief or chair position. Outcome goals are the least controllable as they are the most affected by external influences. There is a general linear relationship between achieving goals from process to performance to outcome; the first type is therefore an area of interest to everyone from professional athletes to hospital executives and beyond. Given that process-oriented goals are the most controllable, it is worth spending time focusing on them.
While running is what I do for “fun,” I also view it as a metaphor for life; whatever activity is most meaningful to you could serve a similar function. Generally speaking, a physically fit person should take 12-16 weeks to train for a marathon with some periodicity (sparing you the boring details but delighted to obsess over and discuss if you are interested), with deliberate practice focusing on foundation, improvement, and peaking for race performance. This is the PROCESS, and deliberate practice, a concept described in detail in Peak by Anders Ericsson and Robert Pool (credit Daniel Nicastri, MD for the recommended reading) is probably the process-oriented goal documented to have the most success in every field. Deliberate practice targets the highest level of performance by repetition, evaluation, and refinement, emulating high achievers in a field and soliciting input from expert outside observers, such as coaches. Ericsson and Pool document example after example as well as strong data to support using deliberate practice, showing how this has resulted in the greatest athletes, chess players, writers, inventors, and musicians in history (think Mozart, Ben Franklin, Lebron James, Serena and Venus Williams, et al.), as well as the highest success for everyday people.
I often say, “They can’t hurt me today.” I’m not sure who “they” are, I guess they could be anyone or anything, but TODAY—today, I’m invincible."
With this in mind, I approached my last marathon (London, October 2022) with a focus on “process-oriented goals” for the race. It was easy to pick a performance or outcome-based goal (a specific time stamp, for example). But then I set out to identify process-oriented goals. This was surprisingly hard but the biggest one was clearly the training cycle itself. Pre-dawn runs, workouts alone or with company, long runs on Sundays with a new sports bra that let me carry my phone wirelessly connected to my watch so I could head home or to the hospital if needed—executing these were my goals in the process and thankfully, I accomplished that. So, for race day, I focused on the following goals: 1) giving it the best I had that day; 2) feeling strong, steady, and inspired by challenges I had overcome; 3) having fun (experiencing the sights, sounds, and cheers!) and not letting my happiness hinge on the actual race time; and 4) enjoying what I describe as the post-marathon bliss (which usually involves pasta and an IPA). Special credit to my family, friends, and partners for covering to allow me to free myself from responsibility for that last one but that post-marathon bliss requires finishing the race to get there. It is the only time I truly let myself off the hook and relax. It is the reason I do all of this, and, after the race, I often say, “They can’t hurt me today.” I’m not sure who “they” are, I guess they could be anyone or anything, but TODAY—today, I’m invincible.
Speaking of today, today’s last hard work out of the training cycle after a late night in the OR—I’ll call it “a win.” Since last October’s race, I have begun to think in terms of process-oriented goals for everything—my career, the operating room, teaching, clinical care, my multidisciplinary mesothelioma program, academic work, and even my health, family, and relationships. I have started to help my team and mentees develop process-oriented goals for themselves and our collaborative work. I recently started meeting weekly with my administrative and mid-level provider team to discuss our practice, workflow, barriers to patient care and productivity, and general aspects of their work they find helpful and not helpful. I certainly have room for growth in my own process (think deliberate practice), but it is a good start. And as far as getting to the other side, I imagine reaping the rewards of the process—“Today. Today, I’m invincible.”
Andrea Wolf, MD
Mount Sinai