Challenging the 'F' word: redefining failure in medical careers

Successful failure. Carl Gray finds that careers must embrace the philosophy of success

Few doctors pass all their examinations first time, take their first choice of jobs at each stage, marry the perfect partner for them, and have 12 perfect children. None will continuously deliver high quality care to universally grateful patients before dying of joy after receiving the monarch's congratulations on his or her 100th birthday. Outside fantasy medicine, no doctor will ever achieve 100% success in any activity, and if they do their evidence base needs careful validating by kindly yet sceptical peers.

Into every life a little rain must fall, and for the opposite of success we think of failure. Unlike the dodo, which is extinct, pandas, which fail to perform in captivity, and tigers, which are threatened, humans are not a failing species. Human ingenuity generally adapts to difficulties of habitat and medical practice. Unlike Cummings' Uncle Sol, no one is born a failure and "Nobody loses all the time."

Yet perception of failure and failing is common in trainees and trainers. The philosophy of failure has received little attention in medicine. But changes are afoot. Soon, the new emphasis on continuous assessment in training will enable us to slay the ancient dragon of categorical failure and embrace the shy maiden of progressive success.

Heroic failure

Of course, admiration of heroic failure is part of the national character. We have had much experience of royal, sporting, and military failures over the years. Traditionally, we admire the playing of the game by the rules rather than the outcome. Dignity in defeat is quintessentially British, allied to the glorious amateur tradition of good chaps trying something difficult with inadequate preparation and technique and cheerfully perishing in the process. Which game should we be playing nowadays?

Classes of failure

We must distinguish the different classes of failure (see box 1). Failure in a competitive situation also involves the independent variable of the other candidates, whose existence and comparative quality set the standard. Regrets - we all have a few, but prescribed standards lead to drab conformity. Better to break the small rules always and the big rules sometimes. Better to seek forgiveness afterwards than permission in advance. But best of all to pass tests first time; to have some time and energy left over for creativity and individual endeavour and editing.
 

A failing profession?

Failure extends beyond the individual: organisational and managerial failure is widely recognised. In a sense, the whole medical profession is currently failing the public in some respects. But success is judged against the available reality; the NHS and its servants can never deliver the whole of their expectations. Success and failure are value judgments made in the eyes of beholders. Single serious errors and bad days abound, but are normal among professionals. What is success and in whose terms? Unfortunately, those who've failed do think themselves failures, and everything and everybody around them remind them of this continually.

Failure in medical careers

A medical career is a succession of exams and selection procedures. Indeed, everyone at medical school is there because many others have failed to be selected at the outset. Failure can afflict anyone doing anything at any stage. Not passing exams, not getting appointed, and feeling that you are in the wrong job are the classic medical failures. Senior doctors are liable to fail later in life by falling below quality standards and losing their enthusiasm and purpose.

Natural responses to failure

Emotional reactions precede rational considerations. Inappropriate responses (box 2) show that there is scope for reality therapy. Usually, an adverse outcome reflects the adverse input into the event. The natural response is to try again immediately and then give up. Medicine is full of fabulous failed folk stuck at grade boundaries, failing to progress, muddling along, or hoping to do something else. The waste of human talent and ability is wanton.
 

Dealing with failure

The principles of recovery from failure are universal (box 3). The only people who can remedy a failure are those responsible. They know who they are in organisations and professions, but in the individual case it happens to be you. Recognise the nature of the failure and research the problem. Advice is available from a wide variety of sources. The experts on an examination are those who have just passed, not the examiners. The comparative standard in a job interview is the successful candidate, although advice on performance can be obtained from the panel members. People happy in their job at your level are the best informants on the choice of a specialty.
 

Recovery depends on applying work to the seat of the problem, accurately and economically. Winston Churchill, whose career showed many reversals of fortune, regarded success as "The ability to go from failure to failure without losing your enthusiasm." It can be done; many of the most successful doctors and editors you will meet have recovered from a failure by focused work.

Remedial strategies

The remedies to failure are essentially to prepare for the next time as you should have prepared for the last. Take one month off to rest, exercise, relax, eat, drink, sleep, and relate. Misery breeds underperformance, so cheer up. Exercise in one subject brings benefits in others. Plan the next five months as your campaign to the next attempt and work hard at it.

The requirements of exams are such that half the population of candidates will succeed above averagely. Indeed, in medical exams median performance is usually above the pass mark. Average people will need average ability, average effort, and average time to achieve the mean result. There is no point being seriously overprepared because overwork brings deleterious effects in fatigue and anxiety, and also to relationships and current workload. Of course, we can all have good days and bad days, good luck or a case of "pseudo-pseudo-hyper-rhubarbism." But luck should be nothing to do with success.

The crux of an attempt on any task is to research the requirements of the test and to prepare yourself to meet them. Preparation must include attitudes, skills, and decision making as well as the body of factual knowledge. Examiners and assessors are usually more concerned with ability, experience, sufficiency, and safety than with factual knowledge carried to abstruse degrees. Candidates usually fail by not demonstrating the basic attitudes, skills, and knowledge required--usually because they have failed to acquire them by experience, having wasted time on other things such as worrying and factual overload.

Adjusting our mindsets

Successful business leaders now give their staff "permission to fail"; a new formulation of the risk to gain ratio. Nothing ventured, nothing gained, and you can't make omelettes without breaking legs if the floor's slippery.

But medical career structures are at last moving away from sudden death, all or nothing tests towards continuous assessment. There is enough success to go round. Trainees should show and be seen to demonstrate a progressive and monitored acquisition of knowledge, skills, attitudes, and experience sufficient to become a competent practitioner. Senior doctors also will be checked periodically to see whether they are still within the happy hunting ground or out where the buffaloes roam.

With the accumulation of progressive success, sudden and unexpected global failure should be very surprising. The results of all examinations should be known in advance. If someone is in the right specialty and making average effort in the right directions, then success will surely follow.

Geniuses have their own problems - outside my experience, although the editor knows some down at the BMJ. Duffers should be guided to evidence of what they can do, not demonstrations of what they cannot.

Calling all failures

Alright, you have failed this exam, or you didn't get that job. Even editors struggle sometimes. You've had a valuable failure, but you will not now become one yourself. The recent disappointment has given you some useful data. This wonderful news informs you of the necessary steps to take. No one thinks any the less of you; you're the same person as before, but enthused and informed for next time. And you know what to do: forget to fail and find your future. "If you can meet with Triumph and Disaster and treat those two imposters just the same"¹ you'll be well prepared and in danger of Success, and all the problems she brings in her train, the cow.

Carl Gray, consultant histopathologist, Department of Histopathology, Harrogate District Hospital, Harrogate HG2 7SX


studentBMJ 1999;07:394-436 November ISSN 0966-6494

1. Kipling R. If. In: Bebbington WG, ed. Famous poems. Huddersfield: Schofield and Sims, 1962:139-40.