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Caris Grimes: clinicians need to learn how to manage failure

Evidence from organisations, education and entrepreneurs highlights the importance of learning how to manage failure. If individuals and organisations learn how to fail well, they develop adaptability, versatility, and resilience and this leads to long-term success, argues Caris Grimes

Medicine is, by its nature, an occupation which attracts people who have a tendency and a history of succeeding. The grades required to obtain a place at medical school are high and the exams during training can be arduous. Many graduating medical students may not have had to face a significant failure prior to starting work. In addition, managing failure is not a subject routinely taught at medical schools.

Yet, all doctors will experience failure. Whether it be complications from treatment or an operation, a delay or error in investigations or results, a complaint from a patient or their family, an unexpected death, a summons to give evidence in the coroner’s court or litigation—all doctors will from time to time suffer from the anxiety, shame, or fear associated with these events. Learning how to manage the response to such events is not something that is currently taught. Research shows that doctors who have recently received a complaint or referral to the Regulator are 77% more likely to suffer from moderate to severe depression than those who have not. They are also more likely to have sleep difficulties, relationship problems, physical health problems and suicidal thoughts.1

One study, which sought to describe the emotional journey that doctors went through after things had gone wrong in the care of a patient, described a number of phases.2 The first phase is a “chaos and accident” response, characterised by turmoil and difficulty concentrating, usually associated with a rapid inquiry as to what happened and why. This is followed by a phase of intrusive reflections, haunted re-enactments, feelings of inadequacy and isolation. The event is gone over time and again in the clinician’s mind with “what if?” scenarios being repeatedly played out.

Following the emotional crash, there is a need to restore personal integrity—rebuilding both self-esteem and the respect that others, personal and professional, hold the individual in. The inability to recover and move forward is often characterised by a lack of supportive colleagues and by a negative culture. This can hamper and impede recovery. The individual then goes through a fourth phase of having to withstand an investigation into the event. They seek emotional support and try to find someone trustworthy to confide in. Finally, one of three things may happen: either the individual drops out of the role they are in (fail badly); they survive, but continue to be plagued and undermined by the event (fail badly); or they thrive (fail well) and are able to make something good come out of the experience.

This is similar to the studies on entrepreneurs facing failure—there is emotional turmoil, there is loss, there is damage to reputation and self-esteem, but if properly supported, there is the possibility of working through it, learning and thriving. 3

Research from organisations, education and entrepreneurs show similar findings; individuals and organisations that only ever succeed can ultimately fail. 4-8  This is because a focus on succeeding leads to a reluctance to change or try anything new, based on the assumption that if nothing changes, the success will continue. However, we live in a world that is constantly changing and therefore there is a need to constantly adapt. An inability to adapt or diversify, may ultimately lead to long term failure.9 But those that learn to fail well ultimately succeed, because failing well (i.e. learning and adapting through failure and learning from mistakes) leads to adaptability, versatility and resilience.

The term “growth mindset” is used widely in education as a tool to helping students learn from mistakes and develop strategies for their own development.  Characteristics of a growth mindset include the belief that intelligence and talents can be developed, mistakes are part of learning, failure is separate from the individual and is an opportunity to learn, and perseverance is crucial. The alternative, the “fixed mindset”, is characterised by a belief that intelligence and talent is fixed, that failures define the person, that flaws and failings should be hidden, and feedback is ignored or seen as a personal criticism, and avoids challenges.10,11 By recognising and learning how to develop a growth mindset, students are encouraged to see failures as opportunities, not feel defined by a failure, and develop solutions and strategies for managing difficulties. Just teaching resilience is not sufficient.

If we want to develop resilient and responsive healthcare systems which protect clinicians as well as learn from mistakes, do we not have to start with learning how to fail intelligently? Do we not need to teach and foster growth mindsets, not just from the point of view of the person involved in failure (“I am not my failure and I can learn and improve from this”), but also from the person tasked with investigating the failure (“This person/s are not their failure and we can all learn and improve from this”)? 

Resilience training alone is not enough. As Winston Churchill is thought to have said: “Success is going from failure to failure without loss of enthusiasm” and “Success is not final, failure is not fatal; it is the courage to continue that counts.”

Caris Grimes, Consultant Colorectal Surgeon, Medway NHS Foundation Trust, Kent, UK. 

Competing Interests: none declared.

References:

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