The Aggregation of Marginal Gains
I don’t know if any of you have heard of James Clear. He is a self-improvement writer and, of all things, a body-builder. The gym and I don’t generally get along, although I have been known to bow to its torturous demands in my youth. Mr. Clear (an awesome and improbable name), despite his sweaty bonafides, is surprisingly good at breaking down the process of getting better at anything. My favorite phrase of his is “The aggregation of marginal gains.”
With this phrase Mr. Clear beautifully describes an attitude I find difficult to the point of impossible to adopt: enjoyment of the process of becoming. A self-confessed serial accomplisher, I have no problem setting goals but tend to suspend my day-to-day happiness until the goal is reached, thus missing a good portion of my life. The process, which Clear calls The System, is really what gets us to the goal. The system is the series of marginal, 1% better, aggregate steps needed on a regular basis to produce improvement. These steps an be almost impossibly small: eating 50 less calories per day, increasing your running mileage by 100 feet, managing to get a note in tune 1% more often in tune. 1% times 100 is – well, 100% better.
This concept, while simple and cognitively understood by most of us, is very difficult to put into practice because marginal gains are hard to see. What is the gain to be seen in getting one note more in tune when a thousand are out of tune? Why do I care if I take two more steps when I run? Americans don’t want marginal gains. We want the big score.
Why am I talking about this on a medical policy blog? Because the knee-jerk reaction many of us physicians have to bad habits is: “You need to stop smoking.” You need to stop drinking.” “You need to check your blood sugar more often.” These statements, while perhaps true, are unhelpful at best and discouraging at worst. The fact that doctors are judged and paid based on results of things likes smoking cessation and blood sugar control doesn’t help. Blanket statements about major changes in habits don’t work. My violin teacher could say “You need to learn how to control your bow better.” Unhelpful. I’ll spend a year tightening my grip and digging into the string until I can’t play at all. Instead he says “lower your shoulder when you come to the base of the bow, and move faster and with more bow hair as you move toward the tip.” If I practice this, the result is that my ability to play one long note may be 1% better. It feels doable. What about those other 100,000 notes? Over time, they all get better. A doctor could say “You need to quit drinking.” Unhelpful. The patient will not drink one day and binge the next. If the doctor says “You need to drink one-half a can of beer less once a week”, it sounds doable. The doctor will not be rewarded for such marginal improvements, but the patient will be, if the aggregation of marginal gains is allowed to proceed in it’s own time.
This approach works for everything. Say you want to get into medical school, but organic chemistry is like a fog that descends upon your brain, so thick you feel like you are swimming through oil-infested gulf water. Instead of quitting that molecular biology and biochemistry major in favor of environmental sociology, figure out how a carbon and a hydrogen fit together. That’s more than 1 % of orgo. That’s like 90%. The aggregation of small advances from that basic knowledge, done systematically and regularly, will get you through.
Marginal gains. You can do it.