Speaker 1: Hello and welcome to the Backstory Podcast where behind every paper there's more to the story. It's just how far back you're willing to go. My name is Ben and I'm here with my good friends Hannah.
Speaker 3: Hi.
Speaker 1: and Justin.
Speaker 4: Hey, how's it going?
Speaker 1: Good to see you all friends. What's new in life?
Speaker 4: Well, here in Pacific Northwest, ⁓ we are dodging the winter blizzard that I think more than half the country is experiencing. So it's actually sunny here in Seattle. So I am very happy about that.
Speaker 3: I have to say on the East Coast, we are not so lucky. It is extremely cold and I am wrapped in as many blankets as I possibly can. I'm dreaming of days at the beach, honestly. I'm just thinking about what it will be like to be on the beach and finally thaw out from this awful blizzard.
Speaker 1: ⁓ yeah, me too. We're bracing forward in Cincinnati where we fear snow like no other. As soon as there's a dusting on the ground, ⁓ people really hunker down and get scared. And I have to say, I'm also reeling right now because my family and I recently moved. So my house is littered with boxes and it's always fun because there's either a cat or a child hiding in the many cardboard boxes scattered around my house and they periodically just pop out as you're walking around the house. And so it's like little Jack in the boxes everywhere. So we are slowly settling in and I am ready for this chaos to die down.
Speaker 3: They're keeping you on your toes.
Speaker 1: Yes, indeed. ⁓ And I have to say, it makes me think of the joy that a cardboard box can bring you. remember those days as a child. All I needed to be happy was a giant box that I could fit inside. ⁓ it makes me just yearn for the days where I was that excited about anything. To just have a box, you give that to my nine-year-old, and she's happy for hours.
Speaker 4: the youngest with two older sisters, I was often the person who was volunteered to be put in the box and pushed down the stairs. So I very much resonate with that.
Speaker 3: Yeah, that's a very younger, youngest child trauma to have. I feel like that's, it was always either cardboard boxes or laundry baskets that my siblings would push me down the stairs in.
Speaker 2: Thanks
Speaker 1: Hold on, just to clarify, because I did not do this. We had a one story house with no stairs. Would you slide down the stairs like a rollercoaster? Like did that work or did you tumble down the stairs?
Speaker 3: with, you know, variable experiences for sure, but kind of like sledding, you know, like in a box slide down the stairs.
Speaker 4: Yeah, it was a combo of the skill of the pusher and the slider. And we at one point had a big mirror at the bottom of our stairs. So you actually kind of wanted to fall before you got to the mirrors.
Speaker 1: I'm just picturing this like now as a parent. If I caught my 14 year old pushing my nine year old down the stairs with a breakable mirror at the bottom, man, I'd have some thoughts for sure.
Speaker 4: You don't need roller coasters if you have stairs with a mirror at the bottom.
Speaker 3: And you see how Justin and turned out, like, you know.
Speaker 1: We're doing great. Yep. You guys are totally fine. You certainly don't start screaming every time you pass a staircase. You guys aren't traumatized at all. It's fine.
Speaker 3: And it certainly wasn't the first thing we thought about when you said, you know, cardboard boxes, so clearly we're...
Speaker 1: Nope. Yeah. Now the Amazon does nothing but bring cardboard boxes to everyone's doorstep. You sure aren't living in a world of terror being ⁓ brought back to your childhood trauma of being pushed down the stairs. Well, speaking of trauma, we have a really interesting paper that I'm excited to talk about. And no, it's not about trauma, but it is about experiences that could be traumatic. And that is failure in the clinical learning environment. This paper is led by Dr. Jennifer Klassen, who's a surgeon. at the University of Basel in Switzerland, along with a powerhouse team of authors. It's titled, Trainees Perceptions of Being Allowed to Fail in Clinical Training, and it's from the journal Medical Education in 2023. Now I chose this paper because I'm a huge fan of Dr. Claussen's work, and it's part of her PhD thesis. It's not a new paper, it's been out for a couple of years now, but I love the conversation it provokes, and I thought it would be a great paper to share. with our HPE community on this podcast, give it a little air time. And also I would love to learn the backstory behind this line of research, because I find it very provocative. Now, lots of people have written about how failure can be generative for learning, but Dr. Klassen has really deeply explored the role of intentionally allowing failure to happen specifically in the clinical learning environment for learning. So this paper evoked a lot of feelings for me, because I've both been allowed to fail and I have allowed others to make mistakes while supervising them. in the clinical learning environment. So this work, this paper builds on work that Dr. Claussen had done previously where she found that clinical supervisors sometimes strategically allow learners to fail when they believe doing so would support learning. Now to clarify, when I say fail, I don't mean failing a test. The authors defined allowing failure as a situation in which quote, while supervising a trainee's clinical performance, the supervisor detects an imminent training mistake. has the opportunity to intervene but chooses not to do so because the educational gain for the trainee is perceived to outweigh the potential consequences for the patient. Now this paper explores trainees perceptions and their experiences around situations in which they're allowed to fail for purposes of learning. So Hannah and Justin, I'm curious, have you ever been allowed to fail in a high stakes environment and how did you feel about
Speaker 4: Maybe I'll take the first stab. Certainly, yes. One that comes to mind is at the end of my first year of nephrology fellowship, I was placing a central line catheter in their necks so could get dialysis. And at my hospital, it's actually not something that the nephrology fellows do very often. It's actually usually the ICU or the emergency room. So I hadn't done it. I had done many during residency, but not so many during fellowship. And so I basically kind of had sought out doing a line. And as I was trying, I had a senior graduate graduating ICU fellow there and basically it was just an incredibly hard line. I was pushing really hard, much harder than I normally would have to. ⁓ Sometimes you have muscles that you have to push through, but it just felt like I was gonna take this needle and stab it deep into their neck. So eventually it was actually the person who was supervising me, they waited until I said, okay, I'm sorry, I can't get this. Can you please help me? And interestingly, that person has put in hundreds and hundreds of lines. also actually could not get the central line into this person's leg. And the attending, also took them substantial effort to get in. And so that was actually slightly affirming for me that if they do it every single day, was still a tough situation.
Speaker 1: What about you, Hannah? Yeah.
Speaker 3: I think the situation that came to mind for me was not necessarily workplace learning, but more informal learning. If you know me, well, you know that I'm visually impaired. And when I started losing my vision when I was in my mid-20s, I started vision rehabilitation called orientation and mobility training, which is the training that you get ⁓ for any individual who's blind or visually impaired. training about how to orient yourself to your surroundings, to navigate safely through new and familiar environments, crossing streets, stop signs, stop lights, all that good stuff. So when I started this training, my O ⁓ instructor was really clear and set the expectation that at some point I would make a mistake and I might fail. And while we were out and about in the community actively working on my navigation skills, she would eventually start to take a back seat and she would start walking further and further away from me so that I was doing more and more navigating independently by myself. And lo and behold, it didn't take very long. I thought I was doing great. We were out working in the community. They crossed a street at an intersection that I thought was a stop sign and it was in fact a stoplight. And about halfway through the intersection, I had crossed a time that I thought was safe. And I almost got hit by a car that was coming at me because I misjudged that this was a stoplight and not a stop sign like I thought it was. And I had a moment of panic. I rushed and finally, you know, crossed the street. And once we got to the other side, my instructor immediately stopped me and was like, okay, how do you feel? Where do we go from here? And actually the most important thing that I learned from that experience was not safely evaluating whether it's a stop sign or a stop light. although I know that now. The thing that I learned most from that experience of being allowed to make a mistake and sort of fail in that moment was how to deal with my own emotions and continue safely navigating and continue going even after I had failed and made this mistake that was dangerous and emotional and difficult for me. Her sort of intervention of, okay, how do you feel and where do we go from here gave me that kind of resilience capacity to do that because... I've continued to make mistakes and failed at times like that. And that was a really great learning experience, actually.
Speaker 1: Thank you both for sharing those. think those are perfect examples of what Dr. Klassen and her colleagues were trying to get at is what role does allowing failure have for purposes of learning? Now to explore this, the authors of this paper used constructivist grounded theory methodology, and they interviewed 15 postgraduate trainees from nine teaching sites in Europe and Canada. What they did was they shared vignettes that they had developed from previous studies. And these vignettes depicted supervisors allowing learners to fail in the clinical learning environment for purposes of learning. So they shared these vignettes with their 15 participants. And they found these participants using purposive and convenient sampling across multiple specialties in these different institutions. They sampled from surgical and medical specialties from a wide variety of specialty surgery, gynecology, urology, pediatrics, and more. They reached theoretical sufficiency after 15 interviews. And one thing I just want to call out, and maybe we can ask Dr. Klassen about, is they wrote that the lead author, Dr. Klassen, knew most of the participants before the interview, is how they wrote it. So I'd be curious to think about if and how that relationship might have impacted the results. the authors use constant comparative approach and iterative data analysis to develop three different themes. So I'm going to pause here before we get to the results. Hannah, Justin, any thoughts on the approach that they took?
Speaker 4: I just have one comment about the, the method constructivist grounded theory. I'm kind of want to nerd out for a second. know, the term constructivist grounded theory actually feels a little bit misleading because the way that people use the method does not necessarily mean that you come from a constructivist framework or paradigm. So my brief sort of tangent is going into theories around the nature of truth or reality. Most of us in medical training, we are trained in the positivist paradigm. where there is a single truth, that we can discover that truth by doing experiments, do things like randomized controlled trials to control for all the factors. Constructivist paradigm believes that there is not a single truth, that truth is constructed individually and that there are multiple truths or realities. But really what constructivist grounded theory is referring to is comparing to classical grounded theory, where you come in without knowing anything about a topic and you basically build a theory that's grounded in the data and only in the data that you've collected. where constructiveness grounded theory is actually bringing in prior knowledge and then building on there and having a theory that's grounded in data. I've used CGT, Constructed Grounded Theory, from a critical theory, critical lens orientation, where I'm focusing on how power creates reality and truth. So I think they do a really nice job of walking us through how they are changing the groups that they're sampling. They start off with surgeons and then... go to medicine and pediatrics, and finally in with folks who are in the health professions research space. And it is a really nicely reproducible study.
Speaker 3: That's so interesting that you say that. I know just from reading the literature that constructivist grounded theory is one of those terms that gets thrown around so often. This paper is such a nice example of using it in a way that's consistent with how Kathy Chalmers and the originators of CGT really thought about the method. So I find this paper to be a really nice example. You said, Justin, that others could follow.
Speaker 1: Fantastic. Thank you both. So what did they find using this constructivist grounded theory? Well, first, their first theme found that failures are common, that they're valuable for learning, and then at times there can be very emotional experiences. I think this is probably what most of us would expect. We've all experienced failure and we've all learned from them. But where things get really interesting to me is the second theme. And what participants said is that despite perceiving that supervisors were allowing them to fail for the sake of learning, so they knew what was happening, They said that their supervisors rarely explicitly acknowledged doing so or provided a rationale for doing so. So they were kind of left to wonder why it was happening. And in the absence of such a discussion, learners tried to make sense of things on their own. The third theme dives into that sense-making process. So for learners, what was most important was the intention of the supervisor, or at least the perceived intention of the supervisor. If learners thought that their supervisor was allowing failure for learning, and it was not threatening patient safety, then they thought it was a good thing to experience. However, if the supervisor's intention was perceived to be malignant or inappropriate, then the failure was seen as destructive and akin to bullying or humiliation or even laziness. Now remember, the supervisors didn't really acknowledge allowing failure. And so these intentions are usually inferred by the learners from their supervisor's behavior. And indeed, the authors did find that learners reacted differently. to the same vignettes that they were discussing and the same experiences that they were remembering. So variable interpretations of being allowed to fail depending on the learner and how they were perceiving the intentions and the actions of their supervisors. So there's really kind of a gap there where a lot can happen in terms of making sense of what's happening. So I'm gonna pause one more time and say, Hannah and Justin, how do these findings sit with you?
Speaker 3: There's a really interesting sentence in the discussion where the authors say that, quote, even if the attribution of destructive intent is inaccurate, the negative impact on the learning environment is no less real for the trainee perceiving this mistreatment. And it got me thinking quite a bit about the gap between intentions and impact. And we see this so frequently between educators who may have well-intentioned efforts to improve learning and yet The impact that it has on a trainee is a harmful impact. And sometimes even the intention of the educator is unconscious. There's not even an intention necessarily prescribed to it, but the trainee feels that impact. What I love about this sentence and about this paper as a whole is that it treats the trainees' understandings, the impacts of failure as real and valid, understanding that this is an impact that happens whether or not people are aware of it or whether they are intentionally trying to produce it. I love the fact that the author centered the trainees' perspectives and that they acknowledge their feelings and their experiences as completely valid.
Speaker 4: One of my takeaways from this paper is I care a lot about thinking about safety in the learning environment. And one of the big topics that many people bring up when you talk about safety is people will say, in learning environments, people need to be uncomfortable. They need to be pushed. They need to be allowed to fail. And if we just have safety all the time, then people won't grow. I think this actually breaks that dichotomy because it shows that even in failure, there can be safe failure and there can be unsafe failure. And to me, it's a cool representation of that.
Speaker 1: Totally agree. And my main takeaway is just what a human enterprise education is. I mean, at the core of it, that's really what we are as educators is we're humanists. And I think about my own day-to-day life and how the way I receive different words or actions varies greatly depending on my perceived intentions of the person. And that's why some of my friends and family members can say and do things that won't upset me. But if a total stranger did them or somebody I perceive to have bad intent, it would. Or sometimes it's the opposite. Sometimes I'm pretty sure my kids are just trying to trigger me into being mad or something like that. This study really just reflects life and humans to me. And ⁓ for that reason, I really, really love it. So to summarize. Supervisors sometimes allow trainees to experience failure in the clinical learning environment and trainees acknowledge that failures can be powerful for learning, but the perceived supervisor intent and patient safety play a role in the impact of such strategies. Unfortunately, supervisors rarely explicitly talk about allowing failure as a teaching strategy, which leaves things open to trainee interpretation and can lead to harm. So Hannah, Justin, do you have a hot take for this paper?
Speaker 4: It's a cheating hot take because I once heard Dr. Klassen speak in person. This is at the AAMC conference a few years ago and she was the keynote speaker for the research in medical education. And you know, people were up in arms and like, we can't let people fail. This is completely unethical, all these things. And she said, you know, let's be clear. Every time we as attendings go home and we leave the trainees in the hospital unsupervised, we're allowing them to fail. So until everyone is willing to spend all their nights in the hospital, I think this is a topic that feels very relevant and that we should learn about. And so that's my hot take.
Speaker 3: Mine is that when a supervisor allows a trainee to have to go through the sense-making process on their own and receive the harmful mistreatment impacts of a failure that has gone unaddressed and unacknowledged, that that's really a failure on the part of the supervisor and not on the learner.
Speaker 1: My hot take is that words matter. And I've talked about some of her work to many people. Some people have big reactions like you described, Justin, and I really think it's the word failure. I think if we use the word mistakes instead, people would feel a little more comfortable with this whole idea. And so just the idea of what we call things, is it a mistake or is it a failure or does it matter what you call it, I think sets the tone for the whole conversation. So I like the fact that we're using the word failure because it really drives home the stakes of some of these moments with patients and I think sometimes calling it a mistake makes it little more palatable as an educational tool. I can't wait to learn from Dr. Klassen and thank you listeners for joining us on the Backstory Podcast.
Speaker 4: We are so lucky and so excited to be joined by Dr. Jennifer Clausen, who is a surgeon, a senior consultant at the University of Basel. She is both a physician and a PhD researcher. We are so excited to have you join us. Dr. Clausen, welcome to the Backstory Podcast. Thank you for joining us.
Speaker 2: Hi guys, thank you for having me.
Speaker 4: Just to start, can you tell us how you prefer to be called?
Speaker 2: ⁓ Jen is totally fine.
Speaker 4: All right, thanks Jen. To start, can you just tell us who you are, what you do, and one thing that listeners might not know about you?
Speaker 2: As you already mentioned, I'm a surgeon. work and live in Switzerland. Originally, I'm from Germany, but live and work in Switzerland at the University of Basel. I'm also a mother of a four-year-old. And probably what most people don't know about me, that we started having a little Easter project last year. And the result is that we are now owners of six hens, silk chickens. And now they started to give us daily some eggs. So that is our little garden project right now, in the last couple of months. Yeah.
Speaker 4: That's amazing. sounds like we have to take a trip to Basel so we can do a proper Easter egg hunt.
Speaker 2: Yeah, that is a possibility in our little garden, yes.
Speaker 4: Can you tell us what got you interested in this work and what led to this paper?
Speaker 2: That's a longer story to be honest. Working as a surgeon you experience ⁓ some failure in your career. So starting as a resident you may fail quite a lot to be honest. Then being a supervisor you often, sometimes on a daily basis, see your residents fail. and I experienced a specific situation in the operation theatre where I consciously allowed a failure to happen. So I assisted a laparoscopic cholecystectomy which is the removal of a gallbladder. It was a pretty straightforward surgery and I had a good relationship with the senior resident of mine. So she is normally very confident in this procedure, but at a specific point in that particular surgery, she pulled too much tension on the gallbladder. And I could, I warned her a couple of times because that specific liver was a fatty one and that could behave like a chocolate pudding. So if you give too much tension on that tissue, it could tear apart and start to bleed. And I warned her a couple of times and In the next single situation I thought, okay, if she's doing it again, I won't say anything in that situation. And it happened again. And liver tore slightly and started to bleed. It was a tiny situation. She solved it on her own. ⁓ But she was like... surprised and that she had to handle this little bleeding. She approached me about that situation, wanted to have some feedback and I said to her, we have to tell the patient that we had a little bleeding and you had to resolve the problem. He left the hospital after two days like any other gallbladder without having any issues and he had an issue about the bleed. a bleeding situation and so everything was fine but after a couple of weeks she came back to me and said how influential this situation was for her and it's I started to think about what I thought in that situation I almost had a bad conscience that I allowed her to fail in this situation and Afterwards I started to ask colleagues in informal conversations, hey do you have such situations sometimes where you consciously allow some failure to happen for whatever reason. And then I started to have some academic conversations with colleagues in medical education and then came up with a research program about it.
Speaker 4: I just love this topic so much because one, think it's in some ways somehow it's political because, you know, people don't like thinking about letting trainees fail and don't like thinking about the sort of being practiced on aspect. ⁓ And I just love how you have leaned into it. And I mentioned this earlier in the podcast, but when you spoke at the AAMC conference, people were like, you know, super alarmed about everything that you were saying. And I just, I just love the way you talk about and think about this topic. So I'm so excited to hear your answers to our questions. I think Hannah has the first one for you.
Speaker 3: Sure, yeah. You mentioned in the story that led to this paper about an experience with a trainee or a doctor and how that experience really formed your interest in the topic. But I was also wondering, in the methods you talk about the orientations of the research team informing the study and the reflexivity involved there. And I was curious about your your own experiences of failure among the research team. Like how did you surface and talk about what failure meant to you? How did you move through those emotions or those memories as a team?
Speaker 2: Well, I think first I had to get into a deeper conversation with myself about that topic, right? Because at the beginning it was more about ⁓ I allowed failure to happen as a clinical supervisor. But in the end I had to come back and have this reflect with myself ⁓ how do I handle failure. with me and I have a pretty complicated relationship with it. Like being a surgeon, if you have a complication, I reflect all the time, did I do something wrong? What could I have done better? What was the problem? Was I not in the best performance? So I reflect a lot into myself, which might be problematic. but also maybe the main reason why I was diving so into that research program, right? ⁓ In the team, we had conversations about failure, but we also had perspectives from two main researcher in our team, Lorelein Lingard and ⁓ Eric Griesen, who are not clinicians and they had ⁓ insights about ⁓ to fail as a scholar. I had conversations in the medical education community where people are doing research in that field, but not coming from a clinical background. So there started another conversation about failure, but in the academic background, right? So I think you have to acknowledge that we have different fields where we can fail in our daily life ⁓ and how you reflect. I have a different ⁓ type of personality in my clinical setting than I have or I approach failure in the research field, right? I'm deeply involved into patient safety and ⁓ patient recovery. I'm not that deeply connected to my failure or failed situations in the academic background. So I would say I almost handle failure in that background differently. And I had the opportunity to reflect a lot and write it down in the reflexivity part of my PhD work, how you may approach that topic. and sometimes having a different hat on.
Speaker 4: I'm curious to hear how much you think supervisors or how accurate you think supervisors are around predicting when a trainee will fail.
Speaker 2: I wouldn't say they are accurate. They work, coming from my research, at least with a type of gut feeling, we called it, ⁓ which is probably a mixture of experience, of having a feeling for the situation, of knowing the resident, of a lot of different factors coming together and then they try and understand it and make sense. But in the end, It is a perception, right? You can't calculate it to 100 % certainty. So there will be in the end a specific uncertainty in every situation you decide as a supervisor. And I think the most important thing is that you know about it. You can't guarantee that any situation you allow to happen will resolve or you can fix it. but you have to be aware of that situation. That you have to acknowledge as a supervisor if you use the strategy.
Speaker 1: First of all, I'm fascinated by thinking about the consistency of organs in terms of dessert foods. So I would be I would love to know, you know, if if the gallbladder is pudding, you know, my one question would be like, deliver, I'm sorry, I'm sorry. That's I'm a pediatrician, not a surgeon. But I would love to inventory like what are the consistencies in the terms you all use. But that's for for later, I suppose. Jen, I was fascinated by. how use of the term failure seems to strike people because failure feels so big and final. And I guess my couple of questions are one, could you reframe this using the word mistake or is there something specific about the word failure? And two, do you think people would respond differently to the idea of allowing failure if we said allowing mistakes?
Speaker 2: ⁓ yeah, we had a lot of conversations about that. We started with failure, also reading the literature coming from Manu Kapoor's work on productive failure, where he uses that term without hesitation from my perspective. And it's not a big deal, but coming into medicine where we try and keep patients safe and healthy or getting them better, we have an issue with it. because failure, as I had to learn as a non-native speaker, is a big word in the English language, right? So I'm not sure it would be better if we had decided to use mistake because mistake seems a bit smaller, not having that huge impact, because if you like search the term failure itself, it's almost having always a catastrophic outcome, right? We didn't mean ⁓ it in that way. We had also situation where nothing happened, no bleeding happened, no one was in danger. We had smaller, tiny situations where a wound weren't ⁓ like cleaned the best way. We had ⁓ bigger situations where ⁓ supervisors allowed probably with the worst outcome than it would be without allowing failure. But we decided to use failure coming from the educational background with the intention to allow to happen. I'm not sure it would be better if we would have decided to use mistake. I mean, there are a lot of terms, right? We discussed also error coming from the patient safety literature. In the end, we used failure. Was that a mistake? I'm not sure. ⁓ But we had a lot of conversations and we reflected and we read and deflected or debriefed about it. It was a conscious decision in the end, yes.
Speaker 1: I think this reflects our different specialties as a pediatrician, we would have used the word whoopsie ⁓ in surgery use the term failure. I think it's just, know, we allowed a yeah, we allowed a whoopsie.
Speaker 2: Maybe a whopsie. will start to use that definitely now and call it with my residents also a surgical whoopsie ⁓ and see what happens then. I like it. Yeah, it maybe takes a bit of seriousness ⁓ out of it. I mean, there is an example, I can tell you I started with presenting that research in front of the medical education community, right? So I would describe our community as open-minded, mindful, ⁓ always open about new ideas, welcoming, warmly, everything positive, coming from a surgical background, you know what I mean? But people reacted also, seeing them sitting in the front row. like shaking their hats, like having small conversations about it while I was presenting. And I was, ⁓ my God, what did I do? So I started to present like the easy peasy, whoopsie situations. And people afterwards approached me and said, ⁓ my God, what happened? Why did you, why did the supervisor do that to the patient? And it was like, waiting longer in the emergency department because the resident suggested doing an ultrasound instead of the CT scan, which was probably in that situation the right decision, but the supervisor let it happen because hey, it was a bit of a longer waiting time and they merged. But people approached me and said, my mother was with the same problem. What is wrong with people that they allow that to happen? So even with this whoopsie, allowed example people were stunned so you couldn't do something wrong or right or presenting it there came emotions with it even if you decided to present easy peasy way so I started to present the whole data
Speaker 3: You just mentioned presenting your work, your PhD work also, which is, it has another level of intensity to it, I feel. Presenting that work to audiences and ⁓ seeing people react emotionally, shake their heads, ⁓ side conversations. How did you as an individual researcher? mean, for me, that kind of audience reaction would be very very difficult to handle. I mean, how did you come back from that or process that?
Speaker 2: Yes, well I had conversations with my PhD supervisor I mean amazing people all I learned God from Tunisian and Eric reason here yay for them I Said to them. I don't know what I'm doing I presented people have have hard feelings about it and they say well we will back you up we are there for you and we know what ⁓ we brought us into that research program. So we are there and I said, well, I don't have any reputation. You can lose your reputation, but they were not concerned about it. I think having them in my back or in my corner was a big help and support in that situation. I also was challenged coming from the surgery background that I had to have conversations with my bosses because I had to go into the office and say, hey, by the way, I'm doing a PhD program about that and that. And my former boss said, why are you doing that? And I said, well, it's an important topic. We should talk about it. And he said, well, if you are doing that, you should like. reframe everything and not saying like allowing failure say something different and then I applied for a new job not because of that issue otherwise because I wanted to work again at the University Hospital but there the new boss said why are you doing that that is crazy and by the way you are not allowed to use that teaching approach in my hospital And I'm afraid that you would bring the press with your research projects into my department. So he was very concerned about it. That is what I was going through.
Speaker 1: Just to reflect on something Justin said when we reviewed this paper, Justin, please. I don't mean to put words in your mouth, but you said something along the lines of we are OK with allowing failures or mistakes every time we leave the hospital because we cannot be there for every decision our learners make. So if we want to not embrace this idea, we better rethink how we supervise. thought I thought that was really on the nose. And so I think when people react this way, they're kind of fooling themselves into thinking that we don't allow mistakes and failures all the time. It's part of what training is.
Speaker 4: Those were Jen's words. That's what she said at the double AMC conference. And I feel like it was just the greatest comeback ever that no one could, you know, overrule.
Speaker 1: That's because everybody who supervises trainees was like, ⁓ I don't want to stay every night. And, you know, people are suddenly like, ⁓ I see the I see the like, consequences of the point I'm making.
Speaker 2: Well, I mean, we send the youngest after three or four weeks sometimes into the night shift, right? And the meaner the supervisor is during the day, the more they are afraid to call him during the night. So I don't think we have to have an issue being there, backing them up, let them fail safe. If we leave the hospital, they are doing whatever they, I mean, can if they don't call us.
Speaker 4: I'm curious to hear what is next for you.
Speaker 2: that is a good question. I started to look into failure to rescue. Failure to rescue is more a quality indicator for departments that they can save the patient having a complication, for example, post-operatively. But failure to rescue is more than just a quality indicator in a department, right? They are often first responders, for example, a resident being alone in the night shift or during a night shift and try to save the patient while we are home alone and sleep. But in the end, they are supervisors. They come in back to the first responder and say, hey, you let the patient die because X, Y, and Z, you didn't react correctly, but maybe we missed something during the day. So I started to look into that type of failed situations and experience that trainees are sometimes deeply troubled by such situations and we are not backing them up in any way. So we can do better and we can do more in such situations for example. And regarding the allowing failure topic, there is one study open and left. I would like to... do and that is interviewing patients about it. Not patients being in the hospital, but asking like the society, right? What do you think? Knowing here in the hospital, we sometimes allow failure to happen and see what they think or perceive about such situations. If you have transparent conversations with patients about failure, that you might be surprised how they react. I think it's more important that you are there on the bedside, have that conversation and say, I'm very sorry that happened. It shouldn't have happened. However, X, Y and Z. I have to say that I didn't went so far that I said I allowed failure to happen because nothing like major happened to a patient. under my watch. But still, I mean, we are a teaching hospital and we can fail even if we don't allow it. You know what I mean? So in the end, and that is what one of my supervisor interview partner said, we sometimes have to allow failure to protect the future patient coming afterwards that patient. I think we have to consider the future patient also and not the current patient in that specific situation.
Speaker 3: This has been a powerful conversation and I've learned a lot. ⁓ So for our ending question, we like to ask our guests to recommend something that they're reading. So if there's one thing that you're currently reading or that you've read recently that you've loved that you'd like to share with our audience.
Speaker 2: Ooh, ⁓ I discovered the book, Being in the Library with my four year old, going through the adult books. And the book is called I Could Strangle Him, which is not, which is coming from a German bestselling author and the career and also life coach Martin Wöller. He talks in a humorous way about difficult characters. such as narcissist, a hothead individual, a constant complainer and ⁓ different ways how to like understand them and handle them. So I probably started to read this book ⁓ because I in my field sometimes you have such characters ⁓ and he provides the reader with a lot of examples. So in the end his main message is probably You don't have to swallow everything, which I don't, otherwise you are doomed in surgery. Nor you have to explode and that is more my problematic situation, I would say. So the best way is clear communication, emotional control. I'm working on that. And in the end, strategic thinking. So I can recommend it if you have to work on understanding such characters.
Speaker 3: I love that I'm taking notes for myself. I want to read them. Well, thank you so much for being here, Jen. We've learned a lot. We had a great conversation.
Speaker 2: No. Yeah, thank you for having me. It was fun. I hope it was what you expected or hoped for.
Speaker 3: even better.
Speaker 4: Thanks, everyone.
Speaker 1: Thanks. Thanks, Jen. Great learning about your research.
Speaker 3: at the end of the backstory podcast. The Backstory Podcast is supported in part by the Josiah Macy Jr. Production and editing by Rachel Holloway. Music by Hannah Kakara Anderson. Artwork by Caitlin Rapaldi. The Backstory Podcast is a sponsored project of the Learning Design Collective. Thanks for listening. Just a reminder that the opinions expressed here are our own and don't represent the views of any institutions. This podcast is for informational and entertainment purposes only. For show notes and links, visit our website. If you enjoyed this episode, please subscribe and leave us a review, and check us out on LinkedIn, Instagram, and Blue Sky at The Backstory Podcast.
Speaker 3: Hi.
Speaker 1: and Justin.
Speaker 4: Hey, how's it going?
Speaker 1: Good to see you all friends. What's new in life?
Speaker 4: Well, here in Pacific Northwest, ⁓ we are dodging the winter blizzard that I think more than half the country is experiencing. So it's actually sunny here in Seattle. So I am very happy about that.
Speaker 3: I have to say on the East Coast, we are not so lucky. It is extremely cold and I am wrapped in as many blankets as I possibly can. I'm dreaming of days at the beach, honestly. I'm just thinking about what it will be like to be on the beach and finally thaw out from this awful blizzard.
Speaker 1: ⁓ yeah, me too. We're bracing forward in Cincinnati where we fear snow like no other. As soon as there's a dusting on the ground, ⁓ people really hunker down and get scared. And I have to say, I'm also reeling right now because my family and I recently moved. So my house is littered with boxes and it's always fun because there's either a cat or a child hiding in the many cardboard boxes scattered around my house and they periodically just pop out as you're walking around the house. And so it's like little Jack in the boxes everywhere. So we are slowly settling in and I am ready for this chaos to die down.
Speaker 3: They're keeping you on your toes.
Speaker 1: Yes, indeed. ⁓ And I have to say, it makes me think of the joy that a cardboard box can bring you. remember those days as a child. All I needed to be happy was a giant box that I could fit inside. ⁓ it makes me just yearn for the days where I was that excited about anything. To just have a box, you give that to my nine-year-old, and she's happy for hours.
Speaker 4: the youngest with two older sisters, I was often the person who was volunteered to be put in the box and pushed down the stairs. So I very much resonate with that.
Speaker 3: Yeah, that's a very younger, youngest child trauma to have. I feel like that's, it was always either cardboard boxes or laundry baskets that my siblings would push me down the stairs in.
Speaker 2: Thanks
Speaker 1: Hold on, just to clarify, because I did not do this. We had a one story house with no stairs. Would you slide down the stairs like a rollercoaster? Like did that work or did you tumble down the stairs?
Speaker 3: with, you know, variable experiences for sure, but kind of like sledding, you know, like in a box slide down the stairs.
Speaker 4: Yeah, it was a combo of the skill of the pusher and the slider. And we at one point had a big mirror at the bottom of our stairs. So you actually kind of wanted to fall before you got to the mirrors.
Speaker 1: I'm just picturing this like now as a parent. If I caught my 14 year old pushing my nine year old down the stairs with a breakable mirror at the bottom, man, I'd have some thoughts for sure.
Speaker 4: You don't need roller coasters if you have stairs with a mirror at the bottom.
Speaker 3: And you see how Justin and turned out, like, you know.
Speaker 1: We're doing great. Yep. You guys are totally fine. You certainly don't start screaming every time you pass a staircase. You guys aren't traumatized at all. It's fine.
Speaker 3: And it certainly wasn't the first thing we thought about when you said, you know, cardboard boxes, so clearly we're...
Speaker 1: Nope. Yeah. Now the Amazon does nothing but bring cardboard boxes to everyone's doorstep. You sure aren't living in a world of terror being ⁓ brought back to your childhood trauma of being pushed down the stairs. Well, speaking of trauma, we have a really interesting paper that I'm excited to talk about. And no, it's not about trauma, but it is about experiences that could be traumatic. And that is failure in the clinical learning environment. This paper is led by Dr. Jennifer Klassen, who's a surgeon. at the University of Basel in Switzerland, along with a powerhouse team of authors. It's titled, Trainees Perceptions of Being Allowed to Fail in Clinical Training, and it's from the journal Medical Education in 2023. Now I chose this paper because I'm a huge fan of Dr. Claussen's work, and it's part of her PhD thesis. It's not a new paper, it's been out for a couple of years now, but I love the conversation it provokes, and I thought it would be a great paper to share. with our HPE community on this podcast, give it a little air time. And also I would love to learn the backstory behind this line of research, because I find it very provocative. Now, lots of people have written about how failure can be generative for learning, but Dr. Klassen has really deeply explored the role of intentionally allowing failure to happen specifically in the clinical learning environment for learning. So this paper evoked a lot of feelings for me, because I've both been allowed to fail and I have allowed others to make mistakes while supervising them. in the clinical learning environment. So this work, this paper builds on work that Dr. Claussen had done previously where she found that clinical supervisors sometimes strategically allow learners to fail when they believe doing so would support learning. Now to clarify, when I say fail, I don't mean failing a test. The authors defined allowing failure as a situation in which quote, while supervising a trainee's clinical performance, the supervisor detects an imminent training mistake. has the opportunity to intervene but chooses not to do so because the educational gain for the trainee is perceived to outweigh the potential consequences for the patient. Now this paper explores trainees perceptions and their experiences around situations in which they're allowed to fail for purposes of learning. So Hannah and Justin, I'm curious, have you ever been allowed to fail in a high stakes environment and how did you feel about
Speaker 4: Maybe I'll take the first stab. Certainly, yes. One that comes to mind is at the end of my first year of nephrology fellowship, I was placing a central line catheter in their necks so could get dialysis. And at my hospital, it's actually not something that the nephrology fellows do very often. It's actually usually the ICU or the emergency room. So I hadn't done it. I had done many during residency, but not so many during fellowship. And so I basically kind of had sought out doing a line. And as I was trying, I had a senior graduate graduating ICU fellow there and basically it was just an incredibly hard line. I was pushing really hard, much harder than I normally would have to. ⁓ Sometimes you have muscles that you have to push through, but it just felt like I was gonna take this needle and stab it deep into their neck. So eventually it was actually the person who was supervising me, they waited until I said, okay, I'm sorry, I can't get this. Can you please help me? And interestingly, that person has put in hundreds and hundreds of lines. also actually could not get the central line into this person's leg. And the attending, also took them substantial effort to get in. And so that was actually slightly affirming for me that if they do it every single day, was still a tough situation.
Speaker 1: What about you, Hannah? Yeah.
Speaker 3: I think the situation that came to mind for me was not necessarily workplace learning, but more informal learning. If you know me, well, you know that I'm visually impaired. And when I started losing my vision when I was in my mid-20s, I started vision rehabilitation called orientation and mobility training, which is the training that you get ⁓ for any individual who's blind or visually impaired. training about how to orient yourself to your surroundings, to navigate safely through new and familiar environments, crossing streets, stop signs, stop lights, all that good stuff. So when I started this training, my O ⁓ instructor was really clear and set the expectation that at some point I would make a mistake and I might fail. And while we were out and about in the community actively working on my navigation skills, she would eventually start to take a back seat and she would start walking further and further away from me so that I was doing more and more navigating independently by myself. And lo and behold, it didn't take very long. I thought I was doing great. We were out working in the community. They crossed a street at an intersection that I thought was a stop sign and it was in fact a stoplight. And about halfway through the intersection, I had crossed a time that I thought was safe. And I almost got hit by a car that was coming at me because I misjudged that this was a stoplight and not a stop sign like I thought it was. And I had a moment of panic. I rushed and finally, you know, crossed the street. And once we got to the other side, my instructor immediately stopped me and was like, okay, how do you feel? Where do we go from here? And actually the most important thing that I learned from that experience was not safely evaluating whether it's a stop sign or a stop light. although I know that now. The thing that I learned most from that experience of being allowed to make a mistake and sort of fail in that moment was how to deal with my own emotions and continue safely navigating and continue going even after I had failed and made this mistake that was dangerous and emotional and difficult for me. Her sort of intervention of, okay, how do you feel and where do we go from here gave me that kind of resilience capacity to do that because... I've continued to make mistakes and failed at times like that. And that was a really great learning experience, actually.
Speaker 1: Thank you both for sharing those. think those are perfect examples of what Dr. Klassen and her colleagues were trying to get at is what role does allowing failure have for purposes of learning? Now to explore this, the authors of this paper used constructivist grounded theory methodology, and they interviewed 15 postgraduate trainees from nine teaching sites in Europe and Canada. What they did was they shared vignettes that they had developed from previous studies. And these vignettes depicted supervisors allowing learners to fail in the clinical learning environment for purposes of learning. So they shared these vignettes with their 15 participants. And they found these participants using purposive and convenient sampling across multiple specialties in these different institutions. They sampled from surgical and medical specialties from a wide variety of specialty surgery, gynecology, urology, pediatrics, and more. They reached theoretical sufficiency after 15 interviews. And one thing I just want to call out, and maybe we can ask Dr. Klassen about, is they wrote that the lead author, Dr. Klassen, knew most of the participants before the interview, is how they wrote it. So I'd be curious to think about if and how that relationship might have impacted the results. the authors use constant comparative approach and iterative data analysis to develop three different themes. So I'm going to pause here before we get to the results. Hannah, Justin, any thoughts on the approach that they took?
Speaker 4: I just have one comment about the, the method constructivist grounded theory. I'm kind of want to nerd out for a second. know, the term constructivist grounded theory actually feels a little bit misleading because the way that people use the method does not necessarily mean that you come from a constructivist framework or paradigm. So my brief sort of tangent is going into theories around the nature of truth or reality. Most of us in medical training, we are trained in the positivist paradigm. where there is a single truth, that we can discover that truth by doing experiments, do things like randomized controlled trials to control for all the factors. Constructivist paradigm believes that there is not a single truth, that truth is constructed individually and that there are multiple truths or realities. But really what constructivist grounded theory is referring to is comparing to classical grounded theory, where you come in without knowing anything about a topic and you basically build a theory that's grounded in the data and only in the data that you've collected. where constructiveness grounded theory is actually bringing in prior knowledge and then building on there and having a theory that's grounded in data. I've used CGT, Constructed Grounded Theory, from a critical theory, critical lens orientation, where I'm focusing on how power creates reality and truth. So I think they do a really nice job of walking us through how they are changing the groups that they're sampling. They start off with surgeons and then... go to medicine and pediatrics, and finally in with folks who are in the health professions research space. And it is a really nicely reproducible study.
Speaker 3: That's so interesting that you say that. I know just from reading the literature that constructivist grounded theory is one of those terms that gets thrown around so often. This paper is such a nice example of using it in a way that's consistent with how Kathy Chalmers and the originators of CGT really thought about the method. So I find this paper to be a really nice example. You said, Justin, that others could follow.
Speaker 1: Fantastic. Thank you both. So what did they find using this constructivist grounded theory? Well, first, their first theme found that failures are common, that they're valuable for learning, and then at times there can be very emotional experiences. I think this is probably what most of us would expect. We've all experienced failure and we've all learned from them. But where things get really interesting to me is the second theme. And what participants said is that despite perceiving that supervisors were allowing them to fail for the sake of learning, so they knew what was happening, They said that their supervisors rarely explicitly acknowledged doing so or provided a rationale for doing so. So they were kind of left to wonder why it was happening. And in the absence of such a discussion, learners tried to make sense of things on their own. The third theme dives into that sense-making process. So for learners, what was most important was the intention of the supervisor, or at least the perceived intention of the supervisor. If learners thought that their supervisor was allowing failure for learning, and it was not threatening patient safety, then they thought it was a good thing to experience. However, if the supervisor's intention was perceived to be malignant or inappropriate, then the failure was seen as destructive and akin to bullying or humiliation or even laziness. Now remember, the supervisors didn't really acknowledge allowing failure. And so these intentions are usually inferred by the learners from their supervisor's behavior. And indeed, the authors did find that learners reacted differently. to the same vignettes that they were discussing and the same experiences that they were remembering. So variable interpretations of being allowed to fail depending on the learner and how they were perceiving the intentions and the actions of their supervisors. So there's really kind of a gap there where a lot can happen in terms of making sense of what's happening. So I'm gonna pause one more time and say, Hannah and Justin, how do these findings sit with you?
Speaker 3: There's a really interesting sentence in the discussion where the authors say that, quote, even if the attribution of destructive intent is inaccurate, the negative impact on the learning environment is no less real for the trainee perceiving this mistreatment. And it got me thinking quite a bit about the gap between intentions and impact. And we see this so frequently between educators who may have well-intentioned efforts to improve learning and yet The impact that it has on a trainee is a harmful impact. And sometimes even the intention of the educator is unconscious. There's not even an intention necessarily prescribed to it, but the trainee feels that impact. What I love about this sentence and about this paper as a whole is that it treats the trainees' understandings, the impacts of failure as real and valid, understanding that this is an impact that happens whether or not people are aware of it or whether they are intentionally trying to produce it. I love the fact that the author centered the trainees' perspectives and that they acknowledge their feelings and their experiences as completely valid.
Speaker 4: One of my takeaways from this paper is I care a lot about thinking about safety in the learning environment. And one of the big topics that many people bring up when you talk about safety is people will say, in learning environments, people need to be uncomfortable. They need to be pushed. They need to be allowed to fail. And if we just have safety all the time, then people won't grow. I think this actually breaks that dichotomy because it shows that even in failure, there can be safe failure and there can be unsafe failure. And to me, it's a cool representation of that.
Speaker 1: Totally agree. And my main takeaway is just what a human enterprise education is. I mean, at the core of it, that's really what we are as educators is we're humanists. And I think about my own day-to-day life and how the way I receive different words or actions varies greatly depending on my perceived intentions of the person. And that's why some of my friends and family members can say and do things that won't upset me. But if a total stranger did them or somebody I perceive to have bad intent, it would. Or sometimes it's the opposite. Sometimes I'm pretty sure my kids are just trying to trigger me into being mad or something like that. This study really just reflects life and humans to me. And ⁓ for that reason, I really, really love it. So to summarize. Supervisors sometimes allow trainees to experience failure in the clinical learning environment and trainees acknowledge that failures can be powerful for learning, but the perceived supervisor intent and patient safety play a role in the impact of such strategies. Unfortunately, supervisors rarely explicitly talk about allowing failure as a teaching strategy, which leaves things open to trainee interpretation and can lead to harm. So Hannah, Justin, do you have a hot take for this paper?
Speaker 4: It's a cheating hot take because I once heard Dr. Klassen speak in person. This is at the AAMC conference a few years ago and she was the keynote speaker for the research in medical education. And you know, people were up in arms and like, we can't let people fail. This is completely unethical, all these things. And she said, you know, let's be clear. Every time we as attendings go home and we leave the trainees in the hospital unsupervised, we're allowing them to fail. So until everyone is willing to spend all their nights in the hospital, I think this is a topic that feels very relevant and that we should learn about. And so that's my hot take.
Speaker 3: Mine is that when a supervisor allows a trainee to have to go through the sense-making process on their own and receive the harmful mistreatment impacts of a failure that has gone unaddressed and unacknowledged, that that's really a failure on the part of the supervisor and not on the learner.
Speaker 1: My hot take is that words matter. And I've talked about some of her work to many people. Some people have big reactions like you described, Justin, and I really think it's the word failure. I think if we use the word mistakes instead, people would feel a little more comfortable with this whole idea. And so just the idea of what we call things, is it a mistake or is it a failure or does it matter what you call it, I think sets the tone for the whole conversation. So I like the fact that we're using the word failure because it really drives home the stakes of some of these moments with patients and I think sometimes calling it a mistake makes it little more palatable as an educational tool. I can't wait to learn from Dr. Klassen and thank you listeners for joining us on the Backstory Podcast.
Speaker 4: We are so lucky and so excited to be joined by Dr. Jennifer Clausen, who is a surgeon, a senior consultant at the University of Basel. She is both a physician and a PhD researcher. We are so excited to have you join us. Dr. Clausen, welcome to the Backstory Podcast. Thank you for joining us.
Speaker 2: Hi guys, thank you for having me.
Speaker 4: Just to start, can you tell us how you prefer to be called?
Speaker 2: ⁓ Jen is totally fine.
Speaker 4: All right, thanks Jen. To start, can you just tell us who you are, what you do, and one thing that listeners might not know about you?
Speaker 2: As you already mentioned, I'm a surgeon. work and live in Switzerland. Originally, I'm from Germany, but live and work in Switzerland at the University of Basel. I'm also a mother of a four-year-old. And probably what most people don't know about me, that we started having a little Easter project last year. And the result is that we are now owners of six hens, silk chickens. And now they started to give us daily some eggs. So that is our little garden project right now, in the last couple of months. Yeah.
Speaker 4: That's amazing. sounds like we have to take a trip to Basel so we can do a proper Easter egg hunt.
Speaker 2: Yeah, that is a possibility in our little garden, yes.
Speaker 4: Can you tell us what got you interested in this work and what led to this paper?
Speaker 2: That's a longer story to be honest. Working as a surgeon you experience ⁓ some failure in your career. So starting as a resident you may fail quite a lot to be honest. Then being a supervisor you often, sometimes on a daily basis, see your residents fail. and I experienced a specific situation in the operation theatre where I consciously allowed a failure to happen. So I assisted a laparoscopic cholecystectomy which is the removal of a gallbladder. It was a pretty straightforward surgery and I had a good relationship with the senior resident of mine. So she is normally very confident in this procedure, but at a specific point in that particular surgery, she pulled too much tension on the gallbladder. And I could, I warned her a couple of times because that specific liver was a fatty one and that could behave like a chocolate pudding. So if you give too much tension on that tissue, it could tear apart and start to bleed. And I warned her a couple of times and In the next single situation I thought, okay, if she's doing it again, I won't say anything in that situation. And it happened again. And liver tore slightly and started to bleed. It was a tiny situation. She solved it on her own. ⁓ But she was like... surprised and that she had to handle this little bleeding. She approached me about that situation, wanted to have some feedback and I said to her, we have to tell the patient that we had a little bleeding and you had to resolve the problem. He left the hospital after two days like any other gallbladder without having any issues and he had an issue about the bleed. a bleeding situation and so everything was fine but after a couple of weeks she came back to me and said how influential this situation was for her and it's I started to think about what I thought in that situation I almost had a bad conscience that I allowed her to fail in this situation and Afterwards I started to ask colleagues in informal conversations, hey do you have such situations sometimes where you consciously allow some failure to happen for whatever reason. And then I started to have some academic conversations with colleagues in medical education and then came up with a research program about it.
Speaker 4: I just love this topic so much because one, think it's in some ways somehow it's political because, you know, people don't like thinking about letting trainees fail and don't like thinking about the sort of being practiced on aspect. ⁓ And I just love how you have leaned into it. And I mentioned this earlier in the podcast, but when you spoke at the AAMC conference, people were like, you know, super alarmed about everything that you were saying. And I just, I just love the way you talk about and think about this topic. So I'm so excited to hear your answers to our questions. I think Hannah has the first one for you.
Speaker 3: Sure, yeah. You mentioned in the story that led to this paper about an experience with a trainee or a doctor and how that experience really formed your interest in the topic. But I was also wondering, in the methods you talk about the orientations of the research team informing the study and the reflexivity involved there. And I was curious about your your own experiences of failure among the research team. Like how did you surface and talk about what failure meant to you? How did you move through those emotions or those memories as a team?
Speaker 2: Well, I think first I had to get into a deeper conversation with myself about that topic, right? Because at the beginning it was more about ⁓ I allowed failure to happen as a clinical supervisor. But in the end I had to come back and have this reflect with myself ⁓ how do I handle failure. with me and I have a pretty complicated relationship with it. Like being a surgeon, if you have a complication, I reflect all the time, did I do something wrong? What could I have done better? What was the problem? Was I not in the best performance? So I reflect a lot into myself, which might be problematic. but also maybe the main reason why I was diving so into that research program, right? ⁓ In the team, we had conversations about failure, but we also had perspectives from two main researcher in our team, Lorelein Lingard and ⁓ Eric Griesen, who are not clinicians and they had ⁓ insights about ⁓ to fail as a scholar. I had conversations in the medical education community where people are doing research in that field, but not coming from a clinical background. So there started another conversation about failure, but in the academic background, right? So I think you have to acknowledge that we have different fields where we can fail in our daily life ⁓ and how you reflect. I have a different ⁓ type of personality in my clinical setting than I have or I approach failure in the research field, right? I'm deeply involved into patient safety and ⁓ patient recovery. I'm not that deeply connected to my failure or failed situations in the academic background. So I would say I almost handle failure in that background differently. And I had the opportunity to reflect a lot and write it down in the reflexivity part of my PhD work, how you may approach that topic. and sometimes having a different hat on.
Speaker 4: I'm curious to hear how much you think supervisors or how accurate you think supervisors are around predicting when a trainee will fail.
Speaker 2: I wouldn't say they are accurate. They work, coming from my research, at least with a type of gut feeling, we called it, ⁓ which is probably a mixture of experience, of having a feeling for the situation, of knowing the resident, of a lot of different factors coming together and then they try and understand it and make sense. But in the end, It is a perception, right? You can't calculate it to 100 % certainty. So there will be in the end a specific uncertainty in every situation you decide as a supervisor. And I think the most important thing is that you know about it. You can't guarantee that any situation you allow to happen will resolve or you can fix it. but you have to be aware of that situation. That you have to acknowledge as a supervisor if you use the strategy.
Speaker 1: First of all, I'm fascinated by thinking about the consistency of organs in terms of dessert foods. So I would be I would love to know, you know, if if the gallbladder is pudding, you know, my one question would be like, deliver, I'm sorry, I'm sorry. That's I'm a pediatrician, not a surgeon. But I would love to inventory like what are the consistencies in the terms you all use. But that's for for later, I suppose. Jen, I was fascinated by. how use of the term failure seems to strike people because failure feels so big and final. And I guess my couple of questions are one, could you reframe this using the word mistake or is there something specific about the word failure? And two, do you think people would respond differently to the idea of allowing failure if we said allowing mistakes?
Speaker 2: ⁓ yeah, we had a lot of conversations about that. We started with failure, also reading the literature coming from Manu Kapoor's work on productive failure, where he uses that term without hesitation from my perspective. And it's not a big deal, but coming into medicine where we try and keep patients safe and healthy or getting them better, we have an issue with it. because failure, as I had to learn as a non-native speaker, is a big word in the English language, right? So I'm not sure it would be better if we had decided to use mistake because mistake seems a bit smaller, not having that huge impact, because if you like search the term failure itself, it's almost having always a catastrophic outcome, right? We didn't mean ⁓ it in that way. We had also situation where nothing happened, no bleeding happened, no one was in danger. We had smaller, tiny situations where a wound weren't ⁓ like cleaned the best way. We had ⁓ bigger situations where ⁓ supervisors allowed probably with the worst outcome than it would be without allowing failure. But we decided to use failure coming from the educational background with the intention to allow to happen. I'm not sure it would be better if we would have decided to use mistake. I mean, there are a lot of terms, right? We discussed also error coming from the patient safety literature. In the end, we used failure. Was that a mistake? I'm not sure. ⁓ But we had a lot of conversations and we reflected and we read and deflected or debriefed about it. It was a conscious decision in the end, yes.
Speaker 1: I think this reflects our different specialties as a pediatrician, we would have used the word whoopsie ⁓ in surgery use the term failure. I think it's just, know, we allowed a yeah, we allowed a whoopsie.
Speaker 2: Maybe a whopsie. will start to use that definitely now and call it with my residents also a surgical whoopsie ⁓ and see what happens then. I like it. Yeah, it maybe takes a bit of seriousness ⁓ out of it. I mean, there is an example, I can tell you I started with presenting that research in front of the medical education community, right? So I would describe our community as open-minded, mindful, ⁓ always open about new ideas, welcoming, warmly, everything positive, coming from a surgical background, you know what I mean? But people reacted also, seeing them sitting in the front row. like shaking their hats, like having small conversations about it while I was presenting. And I was, ⁓ my God, what did I do? So I started to present like the easy peasy, whoopsie situations. And people afterwards approached me and said, ⁓ my God, what happened? Why did you, why did the supervisor do that to the patient? And it was like, waiting longer in the emergency department because the resident suggested doing an ultrasound instead of the CT scan, which was probably in that situation the right decision, but the supervisor let it happen because hey, it was a bit of a longer waiting time and they merged. But people approached me and said, my mother was with the same problem. What is wrong with people that they allow that to happen? So even with this whoopsie, allowed example people were stunned so you couldn't do something wrong or right or presenting it there came emotions with it even if you decided to present easy peasy way so I started to present the whole data
Speaker 3: You just mentioned presenting your work, your PhD work also, which is, it has another level of intensity to it, I feel. Presenting that work to audiences and ⁓ seeing people react emotionally, shake their heads, ⁓ side conversations. How did you as an individual researcher? mean, for me, that kind of audience reaction would be very very difficult to handle. I mean, how did you come back from that or process that?
Speaker 2: Yes, well I had conversations with my PhD supervisor I mean amazing people all I learned God from Tunisian and Eric reason here yay for them I Said to them. I don't know what I'm doing I presented people have have hard feelings about it and they say well we will back you up we are there for you and we know what ⁓ we brought us into that research program. So we are there and I said, well, I don't have any reputation. You can lose your reputation, but they were not concerned about it. I think having them in my back or in my corner was a big help and support in that situation. I also was challenged coming from the surgery background that I had to have conversations with my bosses because I had to go into the office and say, hey, by the way, I'm doing a PhD program about that and that. And my former boss said, why are you doing that? And I said, well, it's an important topic. We should talk about it. And he said, well, if you are doing that, you should like. reframe everything and not saying like allowing failure say something different and then I applied for a new job not because of that issue otherwise because I wanted to work again at the University Hospital but there the new boss said why are you doing that that is crazy and by the way you are not allowed to use that teaching approach in my hospital And I'm afraid that you would bring the press with your research projects into my department. So he was very concerned about it. That is what I was going through.
Speaker 1: Just to reflect on something Justin said when we reviewed this paper, Justin, please. I don't mean to put words in your mouth, but you said something along the lines of we are OK with allowing failures or mistakes every time we leave the hospital because we cannot be there for every decision our learners make. So if we want to not embrace this idea, we better rethink how we supervise. thought I thought that was really on the nose. And so I think when people react this way, they're kind of fooling themselves into thinking that we don't allow mistakes and failures all the time. It's part of what training is.
Speaker 4: Those were Jen's words. That's what she said at the double AMC conference. And I feel like it was just the greatest comeback ever that no one could, you know, overrule.
Speaker 1: That's because everybody who supervises trainees was like, ⁓ I don't want to stay every night. And, you know, people are suddenly like, ⁓ I see the I see the like, consequences of the point I'm making.
Speaker 2: Well, I mean, we send the youngest after three or four weeks sometimes into the night shift, right? And the meaner the supervisor is during the day, the more they are afraid to call him during the night. So I don't think we have to have an issue being there, backing them up, let them fail safe. If we leave the hospital, they are doing whatever they, I mean, can if they don't call us.
Speaker 4: I'm curious to hear what is next for you.
Speaker 2: that is a good question. I started to look into failure to rescue. Failure to rescue is more a quality indicator for departments that they can save the patient having a complication, for example, post-operatively. But failure to rescue is more than just a quality indicator in a department, right? They are often first responders, for example, a resident being alone in the night shift or during a night shift and try to save the patient while we are home alone and sleep. But in the end, they are supervisors. They come in back to the first responder and say, hey, you let the patient die because X, Y, and Z, you didn't react correctly, but maybe we missed something during the day. So I started to look into that type of failed situations and experience that trainees are sometimes deeply troubled by such situations and we are not backing them up in any way. So we can do better and we can do more in such situations for example. And regarding the allowing failure topic, there is one study open and left. I would like to... do and that is interviewing patients about it. Not patients being in the hospital, but asking like the society, right? What do you think? Knowing here in the hospital, we sometimes allow failure to happen and see what they think or perceive about such situations. If you have transparent conversations with patients about failure, that you might be surprised how they react. I think it's more important that you are there on the bedside, have that conversation and say, I'm very sorry that happened. It shouldn't have happened. However, X, Y and Z. I have to say that I didn't went so far that I said I allowed failure to happen because nothing like major happened to a patient. under my watch. But still, I mean, we are a teaching hospital and we can fail even if we don't allow it. You know what I mean? So in the end, and that is what one of my supervisor interview partner said, we sometimes have to allow failure to protect the future patient coming afterwards that patient. I think we have to consider the future patient also and not the current patient in that specific situation.
Speaker 3: This has been a powerful conversation and I've learned a lot. ⁓ So for our ending question, we like to ask our guests to recommend something that they're reading. So if there's one thing that you're currently reading or that you've read recently that you've loved that you'd like to share with our audience.
Speaker 2: Ooh, ⁓ I discovered the book, Being in the Library with my four year old, going through the adult books. And the book is called I Could Strangle Him, which is not, which is coming from a German bestselling author and the career and also life coach Martin Wöller. He talks in a humorous way about difficult characters. such as narcissist, a hothead individual, a constant complainer and ⁓ different ways how to like understand them and handle them. So I probably started to read this book ⁓ because I in my field sometimes you have such characters ⁓ and he provides the reader with a lot of examples. So in the end his main message is probably You don't have to swallow everything, which I don't, otherwise you are doomed in surgery. Nor you have to explode and that is more my problematic situation, I would say. So the best way is clear communication, emotional control. I'm working on that. And in the end, strategic thinking. So I can recommend it if you have to work on understanding such characters.
Speaker 3: I love that I'm taking notes for myself. I want to read them. Well, thank you so much for being here, Jen. We've learned a lot. We had a great conversation.
Speaker 2: No. Yeah, thank you for having me. It was fun. I hope it was what you expected or hoped for.
Speaker 3: even better.
Speaker 4: Thanks, everyone.
Speaker 1: Thanks. Thanks, Jen. Great learning about your research.
Speaker 3: at the end of the backstory podcast. The Backstory Podcast is supported in part by the Josiah Macy Jr. Production and editing by Rachel Holloway. Music by Hannah Kakara Anderson. Artwork by Caitlin Rapaldi. The Backstory Podcast is a sponsored project of the Learning Design Collective. Thanks for listening. Just a reminder that the opinions expressed here are our own and don't represent the views of any institutions. This podcast is for informational and entertainment purposes only. For show notes and links, visit our website. If you enjoyed this episode, please subscribe and leave us a review, and check us out on LinkedIn, Instagram, and Blue Sky at The Backstory Podcast.
