Welcome Back, Today, MedUtopia welcomes another new contributor to our ranks! Rachel Lewin. PhD(c) is a doctoral candidate at the Graduate School for Education and Information Studies at UCLA. She is primarily interested in communication in medical settings, both between patients and providers, and between multiple providers. She has worked in Trauma Surgery, General Surgery, Internal Medicine, Emergency Medicine, Mental Health, Simulation, and is currently completing a dissertation on communication in Urgent Care. Her passions include feedback, failure, coaching, and health literacy. You can find her @MedEdUnicorn on Twitter.   

I’m a Ph.D. student. One of the rites of passage in a Ph.D. program is the qualifying exam—and I failed mine. Literally, as I was on a video call learning that I had failed, flowers that my best friend sent me in celebration were delivered. Failing was embarrassing. I was ashamed. And I went out in my world and told everyone that I had failed. My closest friend in my cohort listened to me stress, complain, and fret, as I prepared to attempt the exam again. On my second attempt, I did pass. Much later, long after I passed, this friend told me that she too had failed her qualifying exams on the first try. But we’ve been taught that failure is shameful, that it’s something we must experience alone, and so she couldn’t even tell me about our shared experience until after I retook my exam. Why is this?

Today, I’m here to talk about one of our “dirty” words: failure. Failure isn’t just a dirty word in academia or in medicine, but in much of society. This is absurd, because literally everyone fails, and failure is a critical part of our growth, development, and learning.

Take a moment to think about how a small child develops a skill, like walking. They try, time and time again, and fall down, time and time again, until finally, it clicks and they take a few steps! Until, again, they fall down. Those are failures. The toddler has attempted a skill that is foreign to them, failed over and over, and iterated until they find success. But, I bet that thinking about watching a toddler fall down while learning to walk doesn’t fill you with dread the way that the idea of making a mistake at work does.

Why is that?

Organizational culture. Everyone fails. One of the game changers in how people respond to failing is organizational and team culture. If they are working in a culture of trust, where periodic failure is not only expected, but encouraged, people will be much more likely to take risks and be creative. This is particularly true if leaders model this behavior, making their failures public, demonstrating the process of learning from their failure and iterating on the attempt. In these complex times, this type of behavior is essential to becoming a learning organization!

Jeer pressure. Jeer pressure is the effect by which watching someone else being ridiculed or punished. These behaviors undermine the psychological safety of the team and we become more afraid of failure, more unwilling to take risks, and more concerned about standing out. This is especially true within the house of medicine where the hierarchies, culture of pimping, and the potentially high stakes decisions make medical practitioners and educators particularly susceptible to jeer pressure. (James and Olson, 2000)

One of the dangers of negative organizational culture and jeer pressure is that it results in efforts that are not wholehearted. When failure is an understood potential, it is possible to put in 100%, to take risks and be creative, with the knowledge that if this attempt isn’t successful, future iterations will be.

Someone out there reading this is thinking—but medicine is high stakes! It’s literally life and death, Rachel!Isn’t it wrong to encourage failure under these conditions?

In response to that, I want to offer a couple of pieces of information.

First, not all failures are created equal. Amy Edmondson categorizes failure into three large categories: Preventable failures in predictable operations, unavoidable failures in complex systems, and intelligent failures at the frontier.

Preventable failures in predictable operations are not to be encouraged—these are generally the result of deliberate deviation from the expected action, inattention, inadequate training, etc. These can and should be prevented.

Unavoidable failures in complex systems account for the majority of mistakes and failures made in hospitals. These are often the culmination of a series of small mistakes that line up perfectly to create a larger, more catastrophic failure (Reason’s Swiss Cheese Model). Many times, the particular combination of mistakes has never been seen before. These failures should be analyzed so that equivalent situations can be prevented going forward, but in a complex system, these failures will occur periodically.

Intelligent failures at the frontier are so-called “good” failures, because they are attempts at forward movement. These failures lead to organizational learning and should be encouraged. These are the types of failure I discuss above.

Our medical student and resident learners are engaged in a process of constantly attempting to move forward in both their knowledge and their skills. Thus, it is critical that our learners feel it is safe, even encouraged for them take risks and create broad differential diagnoses, mention findings they think are being overlooked, ask questions, propose plans, etc. It is only through these attempts that they will develop into entrustable, independent, and effective practitioners.

One final note for the naysayer—status as a learner does not automatically mean that all of their failures are intelligent; it simply increases the likelihood. If a learner repeatedly makes the same mistake or type of mistake, these become predictable errors. Join me again for my next post in which we’ll discuss another dirty word closely associated with failure—remediation.

Image Credits:

“Affection” from https://www.stockio.com/free-photo/affection-6