How Do We Handle Failure in Healthcare?
“Fail fast, fail often” doesn’t apply, but there are strategies clinicians can use.
“The impediment to action advances action. What stands in the way becomes the way.” — Marcus Aurelius
Failure is a topic often talked about and often misunderstood. It can be harnessed for self-development and it can create self-doubt. Scores of books and articles have been written on failure and in today’s culture, and we are often told to embrace it. The Silicon Valley mantra “fail fast, fail often” is mentioned in every other book I read.
But that mantra is specific to Silicon Valley. Failing often is not an option in healthcare.
When failure doesn’t only affect you…
As a physical therapist, my failures in the clinic do not only affect me. The mantra in healthcare would be “hurt people fast, hurt people often.” Obviously, this is not and cannot be the case, but failure is a part of healthcare.
In his book How Doctors Think, Author and physician Jerome Groopman discussed this very challenge. One of his mentors, Dr. Karen Delgado, told him, “The hardest thing about being a doctor is that you learn best from your mistakes, mistakes made on living people.”
It’s one thing to make a mistake on a new feature of an app, it’s another thing to make a mistake while treating a patient. I don’t perform surgery, but my mistakes have led to patients seeking unnecessary surgery. I have hurt patients with the inappropriate use of manual therapy and aggressive exercise. My education has fallen on deaf ears when a more skilled clinician could have better guided and helped the patient. The intent was never malicious and I have always remained ethical in my decisions. It is a simple matter of lacking skill and experience. These take time to develop.
How Bias Influences The Way We Treat Patients. Perspectives From The US and UK.
It is imperative to know how to use the information we are given and how to navigate cognitive traps.
Healthcare is not the only field where mistakes have substantial consequences for people other than yourself. Firefighters, police officers, investors, pilots, even managers, can change the lives of people who put their trust in them. We can’t eliminate failure and mistakes, but we can set up our environment and ourselves to minimize their occurrence and maximize the benefit we gain from them.
“The hardest thing about being a doctor is that you learn best from your mistakes, mistakes made on living people.”
— Dr. Karen Delgado
Essentially, everything is an opportunity to improve. Any barrier, or “failure,” leads to further development. In some cases, “failure” is the only way to learn the correct approach. The moment we start fearing making mistakes, is the moment we stall in our professional growth. Nicholas Taleb goes one step further in his book Antifragile.
Taleb advocates to “put yourself in situations that love mistakes” as “errors become more beneficial than harmful.” Mistakes are how we learn, refine, and innovate. But how do we do this in situations where the cost of mistakes is high? Here are a few strategies:
“Mentorship in two sentences: I have high expectations for you and I know you can meet them. So try this new challenge and if you fail, I’ll help you recovery.”
— The Power of Moments by Chip and Dan Heath
- Mentors and teams. Mentors allow you to brush up to the edge of failure, but they don’t allow you to drown. Having a mentor or a team around you, one that isn’t afraid to give feedback and hold you accountable, will allow you to push forward with security to fall back on.
- Build a foundation. In patient-care, the patient-provider relationship is the foundation. I will learn about their goals and can provide more individual care. I will be less susceptible to tunnel vision and more open to feedback.
- Aim small, miss small. Minimize risk when a task is novel and you lack skill or experience. Think like a researcher. Proof of concept, then animal trials, then controlled human trials, then spread to the masses. If I am learning a new intervention (such as manual therapy, exercise, or educational strategy), I will start by practicing on colleagues who can provide technical feedback. Then I will apply it to patients with more predictable responses and with whom I have a strong rapport. Then I may apply the technique to the complex patients I recently met. For more invasive interventions provided by physicians, they will need to fall back on mentoring, shared decision making, and understanding the breadth of research pertaining to the case.
- Turn the mistake into an advantage. If I used the strategies above, critically thought through the decision and minimized the influence of bias, and still, the outcome was poor, then I have learned a valuable lesson that can be applied for future benefit. This only occurs if I reflect on the interaction and why the poor outcome occurred. Some issues only reveal themselves after application, not during practice.
As a clinician, if I always play it safe, not only will I often fail to provide the necessary therapy to meet the desired threshold for a patient to meet their goals, I will develop tunnel vision and simply go through the motions day in and day out. I may think I have all the answers and have established the best approaches, but history tells us otherwise.
“Put yourself in situations that love mistakes.”
— Nassim Taleb
Challenge “indisputable facts.”
History is riddled with “indisputable facts” that were soon discovered to be indisputably wrong. A brief review of the history of medicine will highlight any errors. Bloodletting used to be a gold standard treatment. If a patient failed to improve, it was because they were too far gone, not because they received treatment that lacked efficacy.
One of the drivers behind avoiding changing the status quo and innovation is fear of failure. The loss-aversion effect is powerful and impacts more than gambling decisions. When directly compared or weighted against each other, losses loom larger than gains.
It is important to define a “loss” and a “gain”, as those can be subjective. Outcomes that are better than the reference point are gains, while outcomes below the reference point are losses. Daniel Kahneman wrote:
“Loss aversion implies only that choices are strongly biased in favor of the reference situation (generally biased to favor small rather than large changes).”
Loss aversion can lead to very reserved expectations as a means of psychological protection. The status quo, or current medical condition, can serve as the aforementioned reference point. Another potential reference point is a goal in the future, meaning not achieving a goal is a loss while exceeding it is a gain.
People expect to have stronger emotional reactions (including regret) to an outcome that is produced by action than to the same outcome when it is produced by inaction. One method to address loss aversion is broad framing, which is approaching a situation with a “big picture” lens opposed to looking at each event in isolation.
Loss aversion typically homes in on a single reference point, such as the end goal of returning to the soccer field after injury or a minimal return on investment. Broad framing would highlight all of the progress made and frame setbacks as opportunities and lessons for future development. Conversely, loss aversion and narrow framing is a lethal combination. While loss aversion and negative emotions can significantly dampen expectations, there are instances where a lack of expectation “control” can negatively impact the assessment of the true benefit or harm of intervention.
Our Cognitive Bias Is Ruining Patient Outcomes Data
How do we know if we are providing high-quality care? Outcome tools can help answer the question, but cognitive biases…
I have fallen victim to loss-aversion many times, especially at the beginning of my career. As I have learned to adapt through the application and adjustments of clinical strategies, I have advanced my clinical practice. At the same time, I think it is important to recognize where we have come from.
I wouldn’t go back and change anything.
I have had some entertaining conversations with several colleagues about my extreme laziness and type B personality I had in high school and undergrad. Some of my greatest accomplishments at the time included reading all the Harry Potter books five times, watching all ten seasons of Friends…twice (I lost count of how many times I watched Scrubs but suffice to say that, when watching, I could say the lines before the characters did), and winning three of four fantasy baseball leagues in one season (I came in third in the other league).
For those who know me know, this seems impossible. Granted, I don’t believe anyone is 100% type A or type B, introverted or extroverted. Context is required as we adapt to the situations we are in. Regardless, I not heavily lean towards the type-A side of the scale.
I’ve reflected on whether I would change if I could go back and do it all over. That is a substantial amount of time that could have been put towards working, volunteering, gaining exposure to physical therapy, building relationships, and reading to learn (classics, non-fiction, self-development books, etcetera). However, if I did all those things, I wouldn’t be where I am today. My path, lessons learned, development, and choices would have differed. So, I wouldn’t change anything about what brought me to where I am now. Our past makes us who we are and sets the stage for future successes.
I had endured eleven rejections as a primary author for my first non-case study research paper, but the reviews and comments taught me valuable lessons that led to two publications in major journals of my field, despite lacking formal education in research and being only a few years removed from graduate school. There is always something to learn from failure.
Regardless of the type of failure, there will always be opportunities to learn and improve. If you approach failure as an opportunity to improve and are honest with the people those the failures affect (e.g. patients), you will grow into a much stronger professional and help far more people in the long run. I recall more from patients who failed to improve, papers that were rejected, and crucial conversations that went poorly than my successes. The key is to accept the reality and reasons why and work to improve future treatments.
What Influences Patient Satisfaction more — actions or words?
The specific treatments are only a small portion of the puzzle
The Benefit of the CV of Failure
Without intentional follow-up action, failure is not beneficial. One of the most valuable documents on my computer is my CV of Failure. I structure the document the same as my traditional CV. This difference is it includes all my rejections. This is not meant to be a pity party, but a document I can reflect on.
It is easy to forget the rejections we endured after achieving success. It is easy to become cocky and lazy once we have a string of success. This document keeps me grounded. I frequently update it and therefore am reminded of the failures required to achieve recent successes.
At all times, I have an updated copy of my “CV of Failures” in addition to my traditional CV. It is often a close race as to which is the longer document. Part of my hopes the traditional CV pulls away soon, but does that mean I am no longer pushing myself?
Success and failure are often viewed as the only two outcomes of an action. I do not believe this is the case. You can have both in any situation. I may “fail” to achieve the desired outcome, but I “succeed” in personal growth through the refinement of my technique and approach.
“Fail fast, fail often” is incomplete and inappropriate in many professional arenas. The act of failing is not enough and it is not always necessary. But when we do fail, we must reflect and make adjustments.
“If you apply yourself to the task before you, follow it with right reason seriously, vigorously, calmly, without allowing anything to distract you; expect nothing, fear nothing, be satisfied with your present activities according to your nature, you will be happy; no one is able to prevent this.”
— Marcus Aurelius
Zach is a physical therapist, researcher, and educator whose mission is to challenge the way clinicians think and close the information gap between clinicians and laypersons. Receive a biweekly newsletter containing his latest blog posts, recent research, and articles on critical thinking and healthy living, and recommended books at zacharywalston.com.