Seeing but not believing: Insights into the intractability of failure to fail

Abstract

Context: Inadequate documentation of observed trainee incompetence persists despite research-informed solutions targeting this failure to fail phenomenon. Documentation could be impeded if assessment language is misaligned with how supervisors conceptualise incompetence. Because frameworks tend to itemise competence as well as being vague about incompetence, assessment design may be improved by better understanding and describing of how supervisors experience being confronted with a potentially incompetent trainee. Methods: Following constructivist grounded theory methodology, analysis using a constant comparison approach was iterative and informed data collection. We interviewed 22 physicians about their experiences supervising trainees who demonstrate incompetence; we quickly found that they bristled at the term 'incompetence,' so we began to use 'underperformance' in its place. Results: Physicians began with a belief and an expectation: all trainees should be capable of learning and progressing by applying what they learn to subsequent clinical experiences. Underperformance was therefore unexpected and evoked disbelief in supervisors, who sought alternate explanations for the surprising evidence. Supervisors conceptualised underperformance as: an inability to engage with learning due to illness, a life event or learning disorders, so that progression was stalled, or an unwillingness to engage with learning due to lack of interest, insight or humility. Conclusion: Physicians conceptualise underperformance as problematic progression due to insufficient engagement with learning that is unresponsive to intensified supervision. Although failure to fail tends to be framed as a reluctance to document underperformance, the prior phase of disbelief prevents confident documentation of performance and delays identification of underperformance. The findings offer further insight and possible new solutions to address under-documentation of underperformance. | 1149 GINGERICH Et al.

Professional expectations of perfection stymy remediation and growth

“…Resident preceptors are known to experience a 'failure to fail' 7 (ie an inability to present negative feedback to a struggling student) and even disbelief when there is evidence that a student is underperforming. 8 Moreover, practices such as 'pimping' and related instances of medical student mistreatment implicitly tell medical students that it is shameful to admit that you do not know something. 9 They internalise this lesson, going to great lengths to hide their own ignorance while simultaneously expressing reluctance to question the knowledge or actions of senior physicians when deficits may be on display.…”

“…This reflects a major undertaking for medical education because these ideas are ensconced deeply into the medical professional trajectory. It would require a revamp of how we approach assessment in medical training, with the goal of increasing medical students' comfort with failure as well as preceptors comfort with providing critical feedback, 7,8 encouraging coaching throughout the medical career and promoting or mandating reflective practice as a feature of continuing medical education. 2 Some of these efforts are already underway with the profession's shift towards competency-based medical education.…”

“…Assessment practices in medical education bolster this idea further. Resident preceptors are known to experience a ‘ failure to fail ’ 7 (ie an inability to present negative feedback to a struggling student) and even disbelief when there is evidence that a student is underperforming 8 . Moreover, practices such as 'pimping' and related instances of medical student mistreatment implicitly tell medical students that it is shameful to admit that you do not know something 9 .…”

Understanding and remedying the performance of doctors in training

“…Pushing us beyond such efforts to specify and frame what struggling learners struggle with, Gingerich et al used a grounded theory approach, interviewing educational supervisors in a limited range of specialties who had particular experience with underperforming doctors 2. Noteworthy was that supervisors by default expected trainees to be capable of learning and applying what they learned.…”

“…That said, underperformance in doctors is often difficult to understand and deal with, both for learners and for educators. The study presented in this issue, by Gingerich and colleagues entitled ‘Seeing but not believing: Insights into the intractability of failure to fail’, 2 provides important insights into why this is, by exploring the socio‐cognitive rules that guide how educators conceptualise, recognise, document and communicate underperformance, as a precursor to evaluation and remediation. Here, I reflect on their findings by juxtaposing them with other seminal works in an effort to further explore the stubborn challenge they address.…”