Bad outcomes are a part of life. In the emergency room, where I spend a great deal of my time wrestling with life and death and humanity, bad outcomes are with us constantly. Equipment malfunctions, needed medications are not available, or patients suffer and die despite our best efforts.
No matter how diligently I train, the truth is that I am an imperfect human. I practice an imperfect science (emergency medicine), and I practice it imperfectly. I do everything I can to deliver the best possible care to each person who comes in, but things don’t always go as I would like.
Outside the ER, it’s no less true. We lose the crucial contract to our competitors, an illness strikes a close friend, or fire claims our home. When these difficult events do happen — and they will — we face a difficult choice: we crumble under the weight of what went wrong, or we find a way to move forward, even if that means temporarily going backward.
When things do go wrong, we can use a three-part method to label, understand, and learn from bad outcomes. First, we acknowledge an event as a bad outcome in a way that allows us to finish any truly crucial tasks without being destroyed by what happened. Second, we pause and allow space to occur between ourselves and the event. Finally, we process the event to understand which parts were in our control and identify areas in which we, our teams, and our systems can improve.
Processing things this way will not make you immune to the repercussions and suffering (either for you or others) that can accompany a bad outcome. However, with time and practice, this method will help you improve the way you handle difficult events and generate more productive and useful responses when things do go wrong. While this method works for any kind of bad outcome, it is particularly useful during a crisis — which, conveniently, is when difficult events tend to happen.
First, Label It “Suboptimal”
The first step is to acknowledge that what happened was, in fact, bad. This sounds simple — just say that something went wrong and move on — but there is more to it, especially during an emergency.
Imagine that while driving home one day, the driver of the car next to you becomes briefly distracted, drifts out of her or his lane, and slams into your car. Your tire is blown, and your airbags go off. While thankfully nothing feels broken, this is unquestionably a bad outcome.
Clearly, pretending nothing has happened and attempting to just finish your drive home on the rim of your wheel with the airbag in your lap is not the right answer. Before you can move on, you need to understand the damage and make sure it is safe to continue.
Conversely, staying in the middle of the highway while screaming and sobbing uncontrollably is also clearly not the correct answer. The longer you stay in the middle of the road, the higher your chances of being hit by another car. Additionally, tearing your clothes in grief will not actually help you get back on the road and on to your destination.
The idea then is to find a middle path — to acknowledge that you were in an accident and that you need to take stock of what happened, but to do so in a way that does not further compromise your safety and facilitates getting back on the road.
For me, this middle path is to say — out loud — a phrase that I’ve practiced over time and imbued with meaning: “Well, this is suboptimal.”
Labeling this situation as “suboptimal” acknowledges the difficulty of the situation without pulling me all the way towards thinking about how terrible the situation is by labeling it as “horrible,” or “hopeless,” or something worse.
There is nothing particularly magical about the phrase “this is suboptimal,” and you might find a different phrase suits you better. A colleague of mine in the ER decided recently to go with “uh-uh, Spaghetti-os,” since it accomplished the same mix of acknowledgment without overwhelming him. Former Navy Seal and leadership expert Jocko Willnik talks about a similar idea with the phrase “Stand by to get some.”
Aside from just acknowledging the difficulty of the situation, calling something “suboptimal” does two important things. First, it reminds me briefly of all of the other truly suboptimal places that I have been in before. To get to this moment, I somehow made my way out of each of those. So, I can tell myself that I’ve been in suboptimal places before and I’m in a suboptimal place right now. I’m going to get out of this one, too.
Second, it adds a little bit of lightheartedness and space to the situation. Standing in the ER covered in blood and vomit with yet another screaming patient rolling in can be a stressful situation, to put it mildly. Calling it “suboptimal” is just ridiculous enough to help maintain the proper focus and balance between being not too tight and not too loose.
The idea is that investing situations with unnecessary and unhelpful emotional energy can detract substantially from our ability to function at the top of our game. “This is terrible, everything is falling apart,” produces a distinctly different set of emotions and responses — both in you and in your team — than a more cautiously and correctly worded “this is suboptimal.”
So, start practicing. When something goes wrong, instead of yelling or ignoring it, face it head-on and say, out loud, “well, this is suboptimal.” Watch what happens in your mind as your normal patterns for coping are disrupted and space is created to move forward.
Initially, it might be difficult to put this into practice in complicated or highly emotionally-charged situations, and that is ok. Start processing on small, easy to handle situations and work your way up from there.
Then, Pause and Breathe
After a bad outcome, it is tempting to rush immediately into trying to dissect what happened and learn whatever we can from it. Maybe this is because it hurts so much and we want to do anything other than feel that hurt. Maybe we are scared it will happen again or get worse, and so we want to jump immediately to “fixing it.”
The thing is, immediately after a bad outcome, we are usually not fully ready to process it. We need to find some measure of equilibrium first. We need to pause and create space between the acute phase of our reaction and the learning and growth-focused phase which will come next.
Physiologically, our stress response — triggered in this case either by the bad outcome itself or our fear of it — involves a variety of electrical and chemical signals with far-reaching consequences in our body and our brain. To really process what happened requires our most flexible and creative modes of thinking; to bring these back online, we need to allow our physiologic signals of stress to run their course and wash out of our bodies.
Imagine there was a medication error and your patient in the ER was incorrectly given a dose of an antibiotic to which they were allergic. Unfortunately, the patient went into anaphylactic shock and required a breathing tube and intensive medications to stabilize their blood pressure. It was a difficult situation, and you are angry and upset that the error happened on your watch, and you are sad that this patient suffered something that probably did not have to happen.
In this scenario, how likely is it that you will be immediately able to perform a thoughtful analysis of the medication ordering and delivery system with enough detail to allow you to pinpoint where the error actually occurred?
Instead, your initial thoughts are probably dominated by large, blunt concepts that need to wash out before more flexible and precise thoughts can occur. So, we pause and we breathe.
Putting this idea into practice is simple and straightforward. After you identify a bad situation, just pause and take some deep breaths. If you have a favorite breathing technique, use it. Personally, I use “tactical breathing,” which is sometimes also called “box breathing.”
The shape and form of the pause should be tailored to fit the environment and available resources. After the imagined medication error for example, we might only get a few moments to regroup before the next ambulance comes in, so this pause might be short.
It is important, though, that the pause should be at least 90 seconds. Evolving understanding of how our brains process emotions (from experts like neuroscientist Jill Bolte Taylor, for example) has shown that the initial surge of chemical signaling in a strong emotional response lasts around 90 seconds. Only after that can other, different signaling processes start to take over.
If there really is not even 90 seconds to pause and allow the initial reaction to pass through — and in a crisis, there might not be — then we probably do not have the time to execute the learning/growth phase of our response either.
Instead of trying to process without first pausing, we should just use the initial step (to label it “suboptimal”) and continue doing the critical tasks that need our attention. Later, when we are in a safer and calmer space, we can try again to regroup and start actively learning.
If, however, it is the end of our shift or if a teammate can handle the next case, our pause would likely be longer and would allow us to more fully separate from the event and change our state of mind. There is no exact timeframe for “settling down”, and it might be a few hours or days before we’re really in a place to process and learn from what happened.
The idea, though, is not that we wait until we have zero emotion about an event; for the most difficult events like the loss of a loved one, that might never happen and there is nothing “wrong” or “bad” about emotion. The important part is to take enough space to allow the largest initial wave to pass through us so we can start to set the stage for deeper processing.
Finally, Dig In and Start Learning
So we’ve labeled the situation, and we’ve paused to create space to allow those initial emotions to wash out. Now, it is time to start moving forward, focused on determining what happened and what we can learn from it.
Figuring out what happened to generate a bad outcome can be a complex process, and volumes have been written about how to design and execute root-cause analyses that seek to determine the proximal underlying cause of a problem. (There is a great introduction to root-cause analyses in this video from the Harvard T.H. Chan School of Public Health, or this one on “The five whys” from entrepreneur and writer Eric Ries.)
The salient feature of our post-event analysis — however we choose to structure it — is that it should seek to identify not just what happened, but why it happened and therefore point the way to what we could do about it.
Personally, I often use a version of the 2x2 matrix shown above, which I learned initially from champion poker player Annie Duke in her book Thinking in Bets. The matrix centers on understanding what part of the event was within our control and what was chance.
To do this, it differentiates between a good or a bad outcome — like whether or not a patient lives — and a good or a bad performance — like whether or not I delivered the best care that I could to that patient, given the resources I had available. Performance we can control; outcome we cannot.
Imagine you run a small company that just finished the first day of a crucial industry conference. Unfortunately, your presentation fell apart and your sales numbers were far below what you had predicted. You need to regroup and change gears before the next day of the conference.
So, you gather your staff and use the matrix to debrief: both for the day as a whole, and for individual components (presentation, lead generation, closing, etc.). Your team asks what was a performance issue, and what was an outcome.
Perhaps you do find performance issues — maybe your presentation used an old set of slides, or the person working on lead generation was not properly trained. Perhaps you find outcome issues that were beyond your control — a power outage prevented your software from signing up potential clients.
Likely, you would find a mix of performance and outcomes issues that together help explain what happened and why. You cannot fix the city-wide power grid, but you can get backup power for your servers, load the updated version of your slides, and switch the lead generation task to a more senior person.
The point is, analyzing a bad outcome to clearly define what is within your control and what is not allows you to triage your resources and dedicate your energy to fixing what is most important — not most frustrating or most obvious.
To practice this step, start using the matrix to identify performance and outcome issues after small events, like a near-miss collision on the freeway, or getting thrown in a jiu-jitsu class. Initially, you might actually draw out the 2x2 matrix to use as a visual guide. With time and repetition, identifying the part of a difficult event that you have control over will come more naturally, as will your ability to find ways to address it.
Responding to a bad outcome with these three steps clears your mind and helps you and your team refocus on what is most important to help you move forward. If you have other ways you process and regroup from bad outcomes, in the world of emergency care or otherwise, I would love to hear about them.