The Failure Effect: Why we should share our "failure stories" in medical education

Director’s Corner
 
 
The Failure Effect: Why We Should Share our "Failure Stories" in Medical Education
 
 
By Olivia Davies and Adina Kalet, MD MPH 
 
 

For this week’s Directors Corner Dr. Kalet invited Olivia Davies (MCW-Milwaukee Class of 2021) to co-write this piece on the critical importance of failure to learning and introduce The MCW Kern Fail Forward Initiative …
 

As you read this, I (Olivia) am sitting in a testing center taking my USMLE Step 2 board exam – one of the many hoops through which students are asked to jump gracefully. But the truth is, we don’t always make it through the hoops first time, sometimes not even the second. It feels like a long time has passed since I received the score from my first MCAT exam (a 27 by the old metric), and yet it’s also so personally recent. That application year, I was not accepted to medical school. In fact, it would be another three years before I received a solitary acceptance at the Medical College. I tell you this because I was certain I was the only person who ever had to retake the MCAT or who ever had to reapply to medical school, when the truth is, I’m not. 

 
In medical school, success is expected. Medical students, when they struggle — as all do at some point — experience failure in isolation. Classmates seemingly face no setbacks; struggles are stifled, shameful even. 
 
Educational theorists emphasize the importance of working in groups to enhance learning, yet medical students who “fail” often struggle alone. This façade perpetuated and upheld by our culture of perfectionism creates a deafening silence for those who trip and stumble. 
 
This culture of silence is not only harmful, but it fails to celebrate the many failures that shape our individual stories. Perhaps more importantly, it diminishes the potential flourishing that occurs when individuals who have faced failure nurture those acutely experiencing it.  
 
Melanie Stefan, PhD, a lecturer at Edinburgh Medical School, recently called on all academics to publish their own “failure résumés,” listing programs they didn’t get into, missed opportunities, critical feedback, and other rejections.¹ This idea has taken hold and captured the imagination of many faculty in medical schools and other highly competitive and academic fields. 
 
This past May, the MCW graduating class of 2020 was surveyed for “failure stories” with the promise that these stories would be their legacy for years to come. The goal of this project was to create a platform where current students could visit to not only view the number of students before them who faced similar failures, but read their predecessor’s stories of failure and, in them, find a sense of solidarity, optimism, resilience, and growth. Indeed, the pathway to success in healthcare is paved with failure, and the creation of a culture the lifts individuals up in both failure and success is essential in the fight for resilience and against burnout. 
 
 

My own (Adina) failure resume includes; the year I submitted sixteen grants and received three small ones that all added together did not allow me to continue the work I have poured myself into for years; the papers rejected multiple times, with harsh, often personal critiques; and the numerous leadership positions I sought unsuccessfully. And those are just the professional failures. My husband has shared his “failure resume” with his fellow leaders in a large department in a medical school and routinely shares it with his trainees. We are both tenured professors of medicine - successful professionals, by all accounts. We have both learned that sharing our failures – especially with junior colleagues – is a great way to identify, analyze, and articulate how to fail productively and strengthen those skills. 

 
Failure is critical to learning. But this is true only if the individual who fails doesn’t give up or walk away from continued effort. Of course, all failure necessitates a recovery period, a time to lick one’s wounds, but soon, too, comes the re-envisioning. Deliberate struggle, working until you fail, analyzing and learning from the failure and trying again is at the core of deep learning. 
 
Although the concept has yet to be widely embraced, allowing or even encouraging failure should be an important role for medical school faculty.² Psychologist Anders Ericsson, describes the importance of planful and deliberate practice to the acquisition and maintenance of expertise. There are now many streams of thought about concepts such as “productive failure” or “desirable difficulty” that all lead to one conclusion: failure is transformative. 
 
Here’s why. Becoming a physician, like other optimal performance fields (e.g., competitive athletics, world class chess) requires grappling at the “learning edge.” The idea of a “Zone of Proximal Development” — a term introduced by psychologist Lev Vygotsky in the early 1930’s — identifies that an educator’s roles include the creation of an environment in which learners identify the absolute edge of their knowledge or skills and then the provision of scaffolding and coaching toward aspirational learning. As the student explores the limits of their skills and understanding, failure is inevitable. 
 
Therefore, failure is critical to becoming a great physician. And yet our students are often left to fail alone, to feel shame and a sense of being an imposter. While these feelings may be part of what motivates us to work harder, overcome adversity, persist with what Angela Duckworth has called “grit,” these feelings are also likely part of what contributes to unhealthy stress, a sense of depersonalization-a component of work related “burnout”. 
 
So, what can we do to maximize the growth-promoting value of failure? We can talk about it. We can create respectful and thoughtful ways to routinely share failures. We can recognize and cultivate the strength of character it takes to “fail well.”
 
In his lovely essay³, Benjamin R. Doolittle, MD, MDiv uses lessons from JK Rowling, Oprah Winfrey, and the movie, The Best Exotic Marigold Hotel, to muse on why, in medicine, we do not “fail well.” We often hide mistakes, errors, and failures despite the growing realization that failure is important to developing true expertise. When we fail, we do not truly believe that we are worthy of redemption. “Accepting our faults requires courage and moral strength.” 
 
 
Over 130 students from the MCW Class of 2020 shared their failures in an effort to breakdown walls for future classes – are you ready to share yours? Contact us if you are.
 
 
 
The Fail Forward Initiative is in the process of being finalized. Anonymous student stories and data aggregates will be accessible to those with MCW credentials. If you’re interested in submitting your own failure story to share privately to those with MCW credentials or publicly on the forward facing failure site, reach out to odavies@mcw.edu or akalet@mcw.edu.
 
 
 

1. Stefan M. A CV of failures. Nature. 2010;468(7322):467-467.
2. Klasen JM, Lingard LA. Allowing failure for educational purposes in postgraduate clinical training: A narrative review. Med Teach. 2019;41(11):1263-1269.
3. Doolittle BR. Failure in Residency Education: Lessons Learned From Harry Potter, Oprah Winfrey, and the Marigold Hotel. J Grad Med Educ. 2019;11(2):233-234.

 
 
Adina Kalet, MD MPH is the Director of the Robert D. and Patrica E. Kern Institute for the Transformation of Medical Education and holder of the Stephen and Shelagh Roell Endowed Chair at the Medical College of Wisconsin
 
Olivia Davies is a fourth-year medical student at MCW-Milwaukee who is in the midst of applying for her dermatology residency. She is an associate editor of the Transformational Times. Follow her at @oliviamtdavies.