I failed an exam at medical school (6 steps to bounce back from failure)

The turbulence of the COVID-19 pandemic has affected us all in many different ways. Many students’ education has been impacted — affecting some more than others. My third-year medical school experience wasn’t ideal - from a shaky clinical placement experience to failing one out of two of my summative exams. I was one of a sizable number. It was the nausea-inducing OSCE (Objective Structured Clinical Examination) I sat in May 2021. The OSCE is a practical exam to assess a medical student’s procedural and communication skills in a simulated environment across several timed stations.

I prepared long and hard. The verdict came in: ‘F’ for Fail. I didn’t need to rub my eyes to make sure I wasn’t seeing things — I failed and that was all there was to it. I was disappointed but not crushed — this failure did sting but was not too painful. I’m on a journey to becoming the first medical doctor in my family, it was never going to be easy. Having failed in high-stakes scenarios in the past, I had developed resilience — I was battle-hardened. I already understood that failure is part of life and I’m comfortable with losing every so often. I haven’t always been this way though. In the past, I used to blame and beat myself up, ruminate and believe I had let everyone down when I failed. I wasn’t on the planet long enough to realise that failure isn’t the end of the world (no pun intended).

The medical profession has a dominant culture of ‘show no weakness’ or being seen as perfect — meaning there is no room for failure at any moment. Failure is seen as something to be ashamed of. It’s an attack on the medical professional’s identity, reputation and self-image — many find it difficult to separate who they are from their profession. The culture tells us that doctors are not supposed to make mistakes; this is why mistakes, errors or failures are stigmatised. This has contributed to a plethora of medical student YouTubers creating ‘How I study 15+ hours a day’ clickbait videos; this is in the name of chasing top grades no matter the cost and no matter how consistently fixed the number of the few that will attain them. For a sizable number of students, it’s at the cost of mental, emotional and/or physical wellbeing. Just passing an exam is unacceptable. Every new medical student is initiated into this culture, knowingly or unknowingly, and the outcomes can be very unpleasant. For those who seem to be thriving in this culture, on the surface, it’s only a matter of time before there are signs of burnout.

‘Society, as a whole, has a deeply contradictory attitude to failure.’ — Matthew Syed, Black Box Thinking

Students, before starting medical school, tend to be highflyers academically — it’s one of the conditions for being offered a place. For those who I spoke to the third-year OSCE was the first exam they’d ever failed; it was a shock to the system and a reality check. For me, the experience was a reminder that failure is a part and parcel of life. Failures can be big or small. It just happened that I failed my OSCE and needed to make adjustments to prove that I could meet the standard required to successfully progress to fourth year.

What might come as a shock to you reading this is that my OSCE failure was one of the most important good things to have happened to me at medical school. Looking back I’m glad I failed at that stage because my focussed improvements will make me a better practitioner.

Before I keep going, here’s a quick way to navigate through the article:

1. My first OSCE experience
2. Process your emotions and change your mindset
3. Accept and embrace failure
4. Talk to others about your failure
5. Dissect the problem and focus on key weaknesses
6. Remember you’re not an expert (yet)
7. Clear your head and don’t focus on things going wrong (again)
8. Conclusion

My first OSCE experience

Towards the end of my second year, with the COVID-19 restrictions in full force, I had a gut feeling it wasn’t going to end in time for the beginning of my third year. I ordered a mannequin that a social media poll named ‘Arnold’. He became my companion to the dismay of my housemates. When it came to preparing for my OSCE, and I couldn’t find a medical student/patient to practice my skills with, Arnold came to the rescue.

When it comes to exam preparation my philosophy is: don’t start too early, but don’t start too late — this is 100% applicable to the OSCE. It is important to peak just in time for the exam. If you peak too early you have to maintain the same consistent effort so you don’t forget things because OSCE skills aren’t natural in many ways. There’s no point spending longer than is necessary preparing for something and perform just as well if one had spent less time — that is a potential recipe for burnout. However, you need to give yourself enough time to prepare, pace yourself and take regular breaks. Plus, with many of the physical examinations having similar steps it was easy to confuse things so enough time is needed to prepare.

After gathering advice from senior medical students and carefully analysing the requirements — I gave myself seven weeks of dedicated preparation. I made sure I covered everything in detail — I knew every single procedure and history like the back of my hand but this is what contributed to my failure. I will cover why and how later.

The OSCE arrived in a flash — as this was my first full OSCE experience I said to myself: ‘let’s see how this goes.’ There were ten 12-minute stations (including one rest station). The first 6 stations were fine I thought. Then I hit the rest station and from there, things went somewhat downhill. The rest station was a metaphor for the chasm between heaven and hell according to the feedback meeting to discuss what went wrong (I had accurately judged my performance). After the OSCE I thought I had done enough to pass; I was confident I had passed at least 6/9 stations (which I did). My official feedback had a significantly different story to tell.

It was time to attend a personal feedback meeting with the medical school. The diagnosis was certain: it wasn’t a knowledge or procedural issue, it was an approach problem — a couple of stations were given a ‘yellow flag’ akin to a football referee's yellow card. I had about three weeks to turn things around and had a few big things on the line, which now depended on my resit result. I had attended a photo shoot for a case study discussing my plans for the next academic year and my Spark-supported business start-up, which was published by the University of Leeds Centre for Enterprise and Entrepreneurial Studies. I had a place to study MSc Enterprise and Entrepreneurship at the business school on the line too. If I failed the resit these would have made the above null and void or at least inconveniently delayed. These were running through my mind as I prepared for my resit which triggered what I’ll call resit anxiety. I was able to immediately relate to what would have been going through Anthony Joshua’s head before his rematch with Andy Ruiz Jr. But I had to ignore the potential ‘Fury-Joshua showdown’ and focus on getting over the hurdle right in front of me. My back was against the wall. The rest of this article will cover the 6 steps of what it took to pass my resit OSCE.

Process your emotions and change your mindset

An official letter was sent by the medical school informing me that my resit was my final attempt — this made my belly turn. This was an emotional response — it sparked my low-grade resit anxiety. For others, thoughts such as: ‘I’m not cut out/good enough to be a doctor’ or ‘Medicine isn’t for me’ may pop up. The pang of self-doubt becomes very present. Again, these are normal emotional responses. I had to use my head to approach the situation. You must maintain laser-focus regardless of how you feel about the situation so you can make the best possible decisions to help you perform your best next time around. Engage with your emotions in so far as they a useful to help you move forward. If you find your emotions too overwhelming the university has a number of support channels — including speaking to your personal tutor.

Allow yourself enough time to process the emotions of failure. You may not be used to these emotions so take as long as you need and slowly detach your emotions from your exam performance. This gives you the bandwidth to start planning your comeback story. Once your emotions are under control it’s time to detach them from the situation and look at it dispassionately. You can do this by assessing the positives of your performance — remember that you did get things right. Humans have a bias for negative thinking so it might take some effort to do this but doing so will help you to see that you have the potential to bounce back — to right a wrong if you will. This will help you to build back your self-esteem and get out of that mental rut and develop the eagerness to do whatever it takes to pass the second attempt.

After having been through several painful failures in the past, I simply saw my OSCE failure as just a day out of many days at the office. I was ready to do what I had to do to turn things around. I knew that I could only improve and become a better future medical practitioner. The ‘growth’ mindset, covered in the Innovation, Development, Enterprise, Leadership, Safety (IDEALS) module of the Leeds MBChB curriculum, always pays dividends.

Here’s something radical: don’t even see exam failure as a ‘failure’ — see it as a mistake. Failure actually means you have no opportunity to rectify your performance. Thinking this way might help with making the situation easier to process. I framed my first OSCE failure as simply a mistake. I had a blindspot. As long as I had another opportunity to succeed I hadn’t ‘failed’. If you change the way you frame a failure, and see it as a mistake you can recover from, you might find that any resit anxiety gets a lot milder.

Accept and embrace failure

Humans are fallible creatures — sooner or later you’ll make mistakes both small and big — it’s a mathematical certainty. There are no exceptions to this rule, no matter how perfectly people around you may try to portray themselves. Take full responsibility for failing. Jocko Willink says: ‘take extreme ownership.’ Maybe uncontrollable circumstances played into a poorer outcome than expected. I was frustrated that I wasn’t able to go through a full mock OSCE due to the pandemic, which would have helped me pick up costly performance gaps earlier. But it’s still only up to you and me to turn things around. The earlier you accept this the better the chance you have to make a comeback. Don’t dwell on what you can’t control, focus on what you can control.

There is no rule, written or unwritten, that says you must always have a successful first try. Patience is a key part of success. Once I learnt this I started to take every failure, as they came, as just part of an ongoing process as I move towards a destination. In my early 20s, I accepted that I can’t win every battle even the ones I’ve prepared for. The reason we usually do succeed after thorough preparation is that the blind spots, which you will always have, weren’t significant enough to negatively affect performance to the point of failure. A blind spot is like a microscopic hole in the tube of a bicycle tyre that you won’t notice until your tyre suddenly goes flat. This has led to my many puncture appointments at the Bike Hub. Exam preparation relies on identifying blind spots but you can’t prepare for every one of them because human beings are not all-knowing. In boxing philosophy: you get knocked out by the punch you don’t see coming. With this knowledge understand that there’s only so much you can do in terms of preparation, which means there is always the possibility of failure.

In light of this, the majority of students will have average or ordinary grades — it’s another mathematical certainty — and there’s nothing wrong with this. Good enough doesn't always need to mean extraordinary; extraordinary is simply a rare bonus. Nobody will experience this all the time and definitely not in every area of life or even consistently in an area where you may have achieved great results in the past. We’re all ordinary in many areas, which means mistakes and failures will feature often in our lives. It's virtually impossible for everyone in a cohort to achieve an ‘A’ grade. It doesn’t matter though because as long as you hit the standards you’ll become a doctor and that in itself is a momentous achievement no matter how you slice it. The lowest ranking medical student at graduation is called a what? A doctor — that's right. Now, this isn’t to say you shouldn’t work your socks off and or not try your best but to understand that you don’t need to sell your soul for the pursuit of grades. Grades should never define you.

As I covered earlier, the medical profession has a negative view of failure. It’s easy to see why — a failure could be fatal or harmful to a patient and detrimental to their surrounding network. However, the reality is that medical practice has only improved, and can only improve, through mistakes and failures and learning from them. Nobody can perfectly predict the effects of a particular course of action and sometimes things go wrong. As Noble Prize-winning Daniel Kahneman said in his book ‘Thinking, Fast and Slow’: ‘… luck plays a large role in every success story; it is almost always easy to identify a small change in the story that would have turned a remarkable achievement into a mediocre outcome.’

With this in mind, it is fair to say that failure is a normal part of life, unpredictable and integral to the human experience. Failure is as certain as you smiling at a funny joke or definitely not laughing when you hit your funny bone. Everyone you know, including yourself, has failed and will fail in big ways whether they share this with you or not. Realising this should help with relieving you of the burden of perfection and help you see failure for what it really is: an opportunity to receive feedback and improve your performance.

‘I’ve missed more than 9,000 shots in my career. I’ve lost almost 300 games. Twenty-six times I’ve been trusted to take the game-winning shot and missed. I’ve failed over and over and over again in my life. And that is why I succeed.’ — Michael Jordan

Talk to others about your failure

Everyone processes failure differently and it can be difficult to share failures with others because of the perception of making you look weak or imperfect — your blemishes get revealed. I learnt a long time ago that failure is nothing to be ashamed of. As difficult as it might seem to do I suggest talking to other people about the experience as soon as you can. It normalises the experience and reminds you that failure is intrinsic to the human condition. It spreads the impact across a wider area of contact which makes a failure experience easier to absorb, process and detach from. Plus, the sooner you share the experience the less space it takes up in your mind. Dwelling on failure alone can make things appear a lot worse than they really are. Speaking to someone helps to reframe failure into something constructive.

Research has shown our recollection of experiences isn’t always accurate; we can combine different experiences to create a story that didn’t actually happen. Humans have a number of cognitive limitations that can have a big effect on how we interpret situations. Keeping things in your head feeds into our negativity bias and exaggerates a problem that might not be there. Jumping to conclusions prematurely might make you feel unnecessarily worse. The benefit of telling trusted others about your negative experiences is that you can get an average of what is most probably happening and is usually not as bad as it seems. You then develop an internal locus of control — that is, you become empowered and believe that you can make a positive difference in an undesirable situation.

Another benefit of telling others about your failures is that people around you are more than willing to help you succeed. Once I told people about failing my OSCE I was offered many kinds of useful help that I greatly appreciated and certainly made a difference in my resit performance. As the saying goes: if you don’t ask (or tell) you don’t receive.

Dissect the problem and focus on key weaknesses

You’ve come to terms with exam failure both emotionally and rationally — it’s time to analyse the problem and focus on solving the most important weaknesses. Use hindsight constructively. It’s important to spend most of your time on your weaknesses; don’t think that you just happened to be unlucky to fail and make the mistake of focussing on sharpening your strengths and hope that will make up for any weaknesses that played a role in the exam failure. Albert Einstein once said: ‘Insanity is doing the same thing over and over again and expecting different results.’

In my case, I have a tendency to overprepare for things and not tone things down just enough so things flow. Yes, there is such a thing as overpreparation and its consequences can be just as devasting as being underprepared, especially for an assessment that focuses on ‘how’ you do things not just ‘what’ you know. I approached the OSCE too scientifically, my performance lacked art — the finesse. When I realised this, I remembered a quote from Bruce Lee:

‘Be like water making its way through cracks. Do not be assertive, but adjust to the object, and you shall find a way around or through it. If nothing within you stays rigid, outward things will disclose themselves.

Empty your mind, be formless. Shapeless, like water. If you put water into a cup, it becomes the cup. You put water into a bottle and it becomes the bottle. You put it in a teapot, it becomes the teapot. Now, water can flow or it can crash. Be water, my friend.’ — Bruce Lee

This is what I had to work on over the three weeks I had to prepare. I had to practice going with the flow and not be inflexible with a heavily structured information gathering approach. I needed a balance. Being the logistician that I am, I asked a few friends who had passed their OSCE to recall their approach for each station based on criteria tailored to the feedback I had received about my performance. I examined the anecdotal data, compared it to mine and clearly saw where I fell short. A coursemate, also resitting, who had more of a problem with structure reached out to me and we spent most of our resit preparation time working on our respective weaknesses and it paid off in the end.

Remember you’re not an expert (yet)

As a medical student you are not an expert, at least not for a very long while. You’re learning so that at some point in time you become an expert; this requires a long process of learning, which means you will make mistakes — plenty of them. It’s on the path to expertise that makes it all the more critical to make learning from failure and mistakes your best friend. Research shows that renowned experts and highly-trained professionals can at times not accept they’ve made a mistake or play down a mistake’s implications through what is known in psychology as ‘cognitive dissonance’. You must always be open-minded and adaptable and keep at the forefront of your mind that the path to mastery is filled with potholes you’ll trip over from time to time — it’s all part of the game and a game well played. It’s always better to make mistakes when it doesn’t matter than to make them when it matters.

Clear your head and don’t focus on things going wrong (again)

You’ve faced your weaknesses, wrestled with resit anxiety and have made the necessary adjustments. It’s important to now not let adrenaline get the better of you as it did me in my first attempt. It’s time to relax as much as possible and get into the zone; it’s easy at this stage to worry about failing again, especially when the pressure will be at an all-time high. But this worrying will only stop you from thinking straight and won’t help you show that you’ve learnt from your mistakes.

Slow down and take your time during the resit. For my first exam I overvalued speed and, ironically, I ran out of time. In the resit, I focussed on patient connection and time slowed down. It actually appeared as if time slowed down when I slowed down — I wasn’t tight for time as I was in the first OSCE when adrenaline was in the driver’s seat. It all worked out in the end, I survived and I’ve told the tale.

Conclusion

‘Finally, you must see your career or vocational path more as a journey with twists and turns rather than a straight line.’ — Robert Greene, Mastery

Medical doctors are made, not born. For the layperson looking in, they could easily get the impression that doctors are natural — this thinking would be quickly forgiven. Yes, there are certain attributes and aptitudes doctors have in heaps and bounds that increase the likelihood of being selected to enter a tightly regulated and privileged profession, but none of these things come included fully matured in the human package. They are built upon and honed repeatedly over a long period of time. In fact, this happens over a lifetime, which is why there is an emphasis on lifelong learning in medicine. The medical curriculum involves repeated exposure to topics to make skills in diagnosis and treatment seemingly second nature.

Failure is part and parcel of life and happens far more often than many of us have been led to believe — people just rarely talk about it as often as success. Having a healthy relationship with failure from an early stage will serve you well for the rest of your career.

Until next time.