The F word—talking about failure in medicine

The F-word is a taboo within medicine that causes shock among medical students and doctors—and we are not talking about the profanity here, but instead the word “failure.” Institutionally, medical schools are responsible for ensuring assessments are fair and all students have equal opportunity to achieve their full potential, including equal access to the best training. Assuming that does happen, attention shifts to the individual, and what is clear, is that there are some commonalities across failing experiences irrespective of training stage.

On the latest episode of Sharp Scratch, the team were joined by Rakesh Patel, Clinical Associate Professor in Medical Education, to discuss the shame and guilt associated with academic failure within medicine.

Perfectionism

A degree of perfectionism is necessary to be successful in medicine, and this trait, along with others, is also associated with selection into medical school. Individuals with perfectionist tendencies are often high achieving and not accustomed to academic failure. For the individual, their personal standards are set so high that both the failing outcome, and the likelihood to continually judge oneself on outcomes at assessment, can be problematic.

From the student perspective, the constant drive to “strive for the unachievable” can lead to feelings of failure—not just on paper, but also in terms of their personal mindset. When failing stops being an opportunity to learn from mistakes, but instead “fuels anxiety”, or damages “self-worth”, as Isobel Walker mentioned in the episode, it can become difficult for students who are fixated on performance goals to progress—both academically and emotionally.

The challenge for educators in these situations is to support individuals, by shifting their focus away from the outcome, and towards the controllable factors that may have contributed to the failure.

Competition

Selection into medical school, all the way through to selection for foundation training, specialty training, and appointment into substantive consultant positions, involves competing with others. For medical students, the full impact of competition remains unexplored, but also causes a dissonance with the constant calls for being collaborative with others. The essence of collaboration is cooperation, however being competitive will likely trump being cooperative in the eyes of many. This is because competition is so inherent within medicine: especially where ranking is used for making employment decisions.

“Needing to be competitive against others… that’s just the part of the game,” Rakesh told our panel.

At an individual level, the need to be competitive can influence individuals away from being genuinely authentic and demonstrating the values necessary for being a doctor. The need to be competitive often involves point scoring or seeking out ways in which to distinguish oneself from everyone else, whereas sitting down and speaking with others (patients, peers and staff) carry value beyond the point systems.

Shame and embarrassment

Perhaps the most emotive issue around failing and our perception of being a failure is the feeling of shame. Many would agree that a healthy sense of guilt around failure can actually be a driver for improvement on the basis there are always personal lessons that can be learnt from the experience. However, shame is a more deep-seated feeling which is destructive because it corrodes our belief that we are capable of change. Perhaps the reason medical students feel such shame after poor academic outcomes is because of our fear of how our peers may perceive us; failing an exam is embarrassing. In some situations, there is also the indirect shaming of those who fail which is where medical schools also need to be aware as well.

“If you failed and had to retake the year—would you tell them that you were retaking?”, Nikki recalled being asked by a classmate, “Or would you pretend that it was your first time?”

It is entirely possible that, as medical students, there are members of our cohorts who have failed examinations, formative or summative, and have never told their peers due to their shame. These same individuals may have also not accessed any of the support available to prevent any further downward spiraling of their academic achievement and their wellbeing associated with repeated failures.

Take away messages

Failing and experiences of feeling like a failure are not uncommon, and are likely to remain present as we continue to assess students in competition with each other. On the one hand there is the need to raise awareness about the impact of perfectionism, competition, shame, or embarrassment, since they are part and parcel of the context of medical education. However, there is also a responsibility on individuals and institutions to drive quality in teaching and learning, as well as responding to setbacks with care, compassion, and the right mindset, for example, using terminology such as “not yet” as opposed to “failed.” It can’t always be that everyone gets everything right all of the time, that is impossible. However we can minimise the negative impact on the individual, and maximise the opportunity for growth next time around.

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Isobel Walker, Fourth year medical student, University of Nottingham.

Rakesh Patel, Clinical Associate Professor in Medical Education & Honorary Consultant Nephrologist, Faculty of Medicine & Health Sciences, University of Nottingham.

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Listen to the episode on Spotify or Apple pods

Sharp Scratch episodes to recommend:

Anxiety

How to smash your med school exams

How competitive are you?

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The Sharp Scratch Panel:

Nikki Nabavi, The BMJ, University of Manchester

Isobel Walker, Fourth year medical student, University of Nottingham.

Panel: @nikkixnabavi @issywalker

Guest: @rakeshspatel