Young physicians that are worried about making mistakes, seemingly unmet expectations and research that doesn’t provide the desired outcome- quite often physicians and nurses feel as though they are dealing with failure. Instead, why not seeing them as opportunities to grow? Here on Forward the following are accounts and reflections of healthcare experts that work in different contexts.
We need to learn that we aren’t invincible, Riccardo Varaldo [Read]
Humanity, intuition and passion to fight failure, Diego Cortinovis [Read]
Failure/success: opportunity and awareness, Chiara Nardini [Read]
How to find success in failure, Chiara Cremolini [Read]
Ten thousand attempts to reach the target, Marco Del Riccio [Read]
Failure/success in psychotherapy: a reflection on complexity, Tommaso A. Poliseno [Read]
The secret of failure (success), Serena Goljevscek [Read]
Accepting new challenges to fight failure, Luigia Carapezza [Read]
We need to learn that we aren’t invincible
Riccardo Varaldo, Haematology, Bone Marrow Transplant Centre IRCCS San Martino Polyclinic Hospital, Genoa
What constitute a success and a failure in medicine? First of all, to answer to this question there should be a clear understanding of what its role is. While reflecting on this topic I remembered the words of my high school professor who, when discussing poetry, told us: “The scope of art is shape”. What is the “scope of medicine” though? The obvious answer would be health, but when we look at the definition of health by the World Health Organization medicine lives in a dimension of constant failure. The more appropriate answer would then be that the scope of medicine is care. At this point failure means being unable to manage the care.
I believe there are two separate levels of failure in “taking care”, medical error aside, as this has its own dynamics (whenever there’s no personal fault the error is often the result of structural, organizational issues etc.). An initial level of failure is linked with communication and it’s an aspect that we need to work on a lot. The “words of care” often hold a different meaning to the physician and the patient. For example, are we certain that the survival rate that we measure the success of our clinical trials with has the same meaning to the patient? The other level of failure is somehow intrinsically part of our work and has to do with the human finiteness. Perhaps all of us newly graduate doctors are a bit like the young physician of the Anthology of Spoon River that inspired De André’s song Un Medico (A doctor): “This is why I swore I’d become a doctor…so that cherry trees could bloom again”. However, soon we realise that, despite our efforts, not all cherry trees bloom again. How to deal with it, then? Unfortunately, and at the same time fortunately, we are not equipped enough. We would love to be like Prometheus but we’re a bit more similar to Sisyphus and acknowledging that more often might help us be better physicians.
Failure means being unable to manage the care. Riccardo Varaldo
Humanity, intuition and passion to fight failure
Diego Cortinovis, Medical Director, Medical Oncology, Lung Unit San Gerardo Hospital, Monza
Medical oncology is a fascinating branch of specialist medicine, not so much because it happens to be my daily focus, but because it faces an undoubtedly common pathology that is often difficult to treat and it is continually developing thanks to the understanding of its causative processes. This aspect brings continuous milestones that mean targeted treatments and the increment of survival and recovery rates, even with illnesses at an advanced stage. The emphasis on the scientific side undoubtedly entails the union between the opportunity of career progression through research, daily study, participation in congresses, international work experiences and the recognition within the scientific community that one is part of.
However, daily clinical practice and the current healthcare world dictate different rules, often demanding all-encompassing care, even outside of one’s competence, the inevitable bureaucratic burden and waste of time and energy. This misalignment leads to an inevitable “failure” of one’s expectations, particularly after years of work, which can lead to the onset of burnout symptoms.
During my teaching in different university environments I came across various younger colleagues that keep on highlighting how this difference between ambitions and reality sometimes results in frustration. When reflecting on this seemingly psychological topic, the emerging view is that, once again, it is necessary to go back to the root concept of medicine as centred directly on the person. The world of the ever-changing medical oncology, of the technology applied to clinical practice and of the long wait for long life expectancy even in very challenging conditions, requires humanity, intuition and passion, which are the essence of healthcare. The secret to turning the seemingly failed expectations in successful medicine is to remember that the value of specialist work translates into the patient’s gratitude towards his/her oncologist.
It is necessary to go back to the root concept of medicine as centred directly on the person. Diego Cortinovis
Failure/success: opportunity and awareness
Chiara Nardini, Nurse, Case manager of paediatric chronic conditions Neonatal paediatrics and intensive care unit, Hospital of Ravenna
Writing about one’s own failures isn’t easy. Culturally we are used to give failure a negative connotation and see it as something to hide. When thinking about their years of work in the frontline any healthcare worker recalls some individuals, patients whose case they remember as the clinical condition was elusive, patients whose diagnosis we struggled with, formulating and reformulating hypothesis that made us feel as though we were proceeding with uncertainty and seemingly without a precise direction. If we saw the same case now, would we know how to handle it? We would, thanks to our experience, which is a form of direct knowledge that we acquired through practice. Are we then certain that those cases were a failure? Or rather, viewing things from the right perspective, weren’t they a great learning opportunity? The philosophy of learning from mistakes should be promoted by effective teams, through team members debriefing to better understand the clinical case, the causes, the results and the actions taken to plan the care. In fact only this way it is possible to create workgroups that are resilient and reactive towards errors, where everyone is supported to improve and grow professionally.
I’m a nurse and I work in paediatrics where the word “development” is used daily, both in terms of rate/percentages and in terms of motor and cognitive improvement, where even though the timing and modality vary for each child it is possible to identify in the process a sequence of milestones that are part of the chronology of development. Isn’t this what happens every day while we are at work? In 1951, during the celebration of the Declaration of human rights, Maria Montessori sent a message to the UNESCO, on her “Speech on the forgotten citizen”, where she denounced the mistake of leaving children behind: “There are two forces present in human life: that concerning the period of human development (the child) and that concerning the constructive social activities (the adult). They are so strongly interlinked to one another that neglecting one means we cannot get to the other”. Each one of us was and is that child, wearing our uniform every day, and for this reason we should be ready to look up to failure/success as a milestone of development.
Writing about one’s own failures isn’t easy. Chiara Nardini
How to find success in failure
Chiara Cremolini, Department of translational research and the new medical and surgical technologies, University of Pisa
Conducting an independent research study means formulating very clearly an hypothesis that you are firmly convinced about, putting it down in black and white and testing it by following well defined rules that are detailed in a protocol written at the beginning of the study, without any certainty of the outcome. It takes courage to transform theoretical ideas into clear evidences. It takes energy to overcome the several obstacles found on the way. It takes commitment and dedication to ensure that all the rules of the game are respected, not to compromise the quality of the results. There comes a time for the final analysis. That is the moment of truth, where you get all these feelings- the whiffs and clinical vibrations that you experienced during the study don’t matter anymore- in that moment you immediately know whether the original hypothesis was correct, whether the intuition can be confirmed, whether the theory might shortly translate into practice. The emotional charge of this moment is often compounded by what is at stake: obtaining an improvement, small or big, of our way to deal with various pathologies, offering better chances for upcoming patients. Sometimes- not rarely- the statistical software that we placed our hopes in doesn’t give us the desired outcome. Despite our best hope it gives the final judgement with the icy coldness that only numbers know. Your heart stops for a moment, you blink a few times to ensure you read correctly and your energies suddenly seem to leave you.
The study outcomes are negative. We recorded a failure. It immediately feels as though all the resources invested so far have gone to waste and that it was a mistake to bet on that theory, to stubbornly want to demonstrate that hypothesis. Knowing that you made a contribution, even though with a negative result, towards the advancement of your field and advising the others in the sector not to follow that road is too poor a consolation. However, with a cold mind, you begin to elaborate possible explanations to justify the unexpected results. This is the moment where the researcher, after the initial discouragement, gets new lymph for new attempts from the enigma he/she is facing. Original and brilliant ideas to reach the target anyway often stem from a deeper analysis of the mistake- from the assessment of what caused a different outcome than what was expected- and manage to find success in a failure.
Original and brilliant ideas to reach the target anyway often stem from a deeper analysis of the mistake. Chiara Cremolini
Ten thousand attempts to reach the target
Marco Del Riccio, Specialist School of Hygiene and Preventive Medicine, University of Florence
To fail: [to fail] (I fail; you fail; he/she fails; they fail; he who fails, a failure). Being unable, to not succeed in what you are expected to do, not achieving the set goal.
We all failed at some point in our life, or at least experienced some situations as a failure. It wasn’t too long ago for me. I went through something that perhaps many others have: hours of work at the computer, collecting data, processing it, doing research, writing and staying up late to finish an article in the hope it would get published. You picture how all your efforts will pay off and in the end and convince yourself you did a great job. Instead, you get rejected once, twice, three times. You didn’t get there on time; someone else already did something similar. Clearly it’s not you that gets rejected but you do feel a bit as though it is; you feel like, despite everything, you still didn’t do enough. How can you not think that you failed?
Yet, the vocabulary is clear and the definition doesn’t leave space to interpretation: you fail when you don’t achieve what you are expected to do. Perhaps reality is not as simple though. Failing is a term that many see with a definitively negative connotation. It is wrong to fail, failing means not being enough, not being among those “that made it”, but are we so sure that failing is necessarily bad? When can we really think that we “didn’t make it”?
Thomas Edison’s story is well known. After several attempts where he didn’t manage to build a working light bulb he didn’t say he failed but that he had simply found thousands of ways not to build a light bulb: a simple change of perspective, a different point of view. Maybe the breakthrough is not so much about changing the definition of failure but accepting failure as part of the journey, as a chance to learn, the opportunity to know ourselves. Even though all those hours of work didn’t result in that publication, they made me understand that I want to dedicate myself to research, that that is what I like and that, though you could say I failed this time, I will treasure this experience, try again and find the right way to do things. I also want to be on the same stubborn side of those who achieve their result after ten thousand attempts.
How can you not think that you failed? Marco Del Riccio
Failure/success in psychotherapy: a reflection on complexity
Tommaso A. Poliseno, Psychiatrist, Department of Mental Health, Rome 1 Local Health Authority (ASL) – Group analyst, Group analysis laboratory, Rome
A success in psychotherapy is inevitably made of incompleteness, doubts and “open” truths. In the same way, a failure might be partial, leave fertile tracks or open new explorations. The complex nature of psychotherapy, as a human experience rather than a laboratory one, seems to endure the attempts of those tout courts who, while searching for scientific rigour, try to apply neurocognitive principles to it. As Edgard Morin [1] (French philosopher and sociologist) explains, the theory of complexity is better applied to this field, which is like “a fabric (complexus: that which is woven together) of heterogeneous constituents that are inseparably associated: complexity poses the paradox of the one and the many. […] Hence the necessity for knowledge to put phenomena in order by repressing disorder, by pushing aside the uncertain…But such operations, necessary for intelligibility, risk leading us to blindness if they eliminate other characteristics of the complexus”. According to Morin we risk getting a hyper-specialised knowledge that, losing sight of the bigger picture, becomes hyper-compartmentalised and fragmented. The philosopher suggests a reform of thought in this dimension that heads towards “thinking without ever closing concepts, […], making efforts to understand multi dimensionality, […], not to forget the integrating totalities”.
The concept of integrating totality sits on the extreme opposite pole compared to the reductionist operations that nowadays afflict psychotherapies. It should be the guiding concept for scientific research, especially when we have to learn from our failures. Boisvert and Faust [2] state in their research that on average in 3-10 per cent of the cases patients undergoing therapy also get worse, experiencing serious and irreversible relapses. I would also like to highlight a very interesting 2010 article by Barlow [3] that presents a literature review of the last forty years regarding the intrinsic iatrogenic risk that some therapeutic processes pose. Here are some other good ethical reasons to try and integrate productively success and failure with the help of the theory of complexity.
Success and failure should be integrated productively with the help of the theory of complexity. Tommaso A. Poliseno
References
[1] Morin E. Introduzione al pensiero complesso. Gli strumenti per affrontare la sfida della complessità. Milano: Sperling & Kupfer, 1993.
[2] Boisvert CM, Faust D. Iatrogenic symptoms in psychotherapy: A theoretical exploration of the potential impact of labels, language, and belief systems. Am J Psychother 2002;56:244-59.
[3] Barlow DH. Negative effects from psychological treatments. A Perspective. Am Psychol 2010;65:13-20.
The secret of failure (success)
Serena Goljevscek, Psychiatrist, Trieste
Sometimes simple brackets can help us rethink about ourselves and about what is around us from a suspended point of view, somewhere between “an external and an internal” viewpoint that shapes meanings, making them less stereotypical and less compressed by (pre)judgement. The word failure (success), with these brackets almost seems emblematic, particularly when applied to a very multi-faceted sector such as mental health, which I’ve been delving into for ten years. It is a concept that should be approached with caution, observed a bit from a distance, because it’s always dynamic. It’s a continuous back and forth between “failure” and “success”, within a set of value reference points and social targets that sometimes don’t have much to do with those who struggle with it.
As a support worker what I’m sometimes asked for, as a target to work on with the distressed individuals I see, is the achievement of a (precarious) balance that is as conformed to the general rules of our society as possible. In reality for the other person this can actually become a faded and trivialised fallback version of themselves, (theoretically) accepted by others, but often not recognised by those who have to, more or less consciously, internalise it. This is probably the real failure, without any brackets.
In the book Franco Basaglia, Mario Colucci and Pierangelo Di Vittorio wrote that, “in order to really meet the sick, to fully understand his/her madness, one should go for aggression”. According to this enlightening perspective our institutional failure becomes a relational success. Managing to approach the subjectivity of the other person, in its proud entirety, made of shining creativity but also restless intolerance of living (or life suffering), is the road that leads to the truth of the other person and that allows to seriously accompany the struggling individual on their journey through the pain and the gained awareness of their way of being in the world. A seemingly paradoxical notion, that experiencing a crisis brings richness, emerged here; crisis meant as breakage, the overturn of balances and the loud and vital emersion of the contradictions that fill our human existence. When the current mental health institution has to face the crisis of one of its components it usually goes into a phase of initial dismay due to the loss of references and the questioned health models that were proposed and socially validated; it is a crisis intended as the failure (no success!) of a system that is seen as solidly functional and tailored to the needs of those that inhabit it. On the contrary, turning this perspective upside down and an enlightened revaluation of the meaning that every crisis brings along in the existential experience of the other person allow the mental health support worker to truthfully get closer to the pain, to (understand) “take on” the other person’s reality and at the same time lose part of themselves in the other person, in a continuous shuffle of roles, relationships, experiences and objectives that are created and deconstructed- the pure and essential practice of life.
Our institutional failure becomes a relational success. Serena Goljevscek
Accepting new challenges to fight failure
Luigia Carapezza, CBT psychotherapist and psycho-oncologist, Medical Oncology, Arnas Garibaldi, Catania
“Dear Salvatore, it’s been a long time since I last wrote to you. That’s because I’ve gone through a dark time in my life…between health issues that I successfully overcome and a bad habit I had (I used to drink). Now I can say that I’m trying to turn my life around…and going back to being the Salvatore that I know. You know, I’m really trying to do my best, also thanks to the psychological support from my doctor. These days I’m happy and calm. I go to work in the morning and then draw a bit, which, as you know, I’ve always loved to do. I might go for a bike ride if the weather allows. I’ll keep you updated with always greater news. Hugs.”- S., Catania, 1st June 2016.
I faithfully quoted the words that Salvatore dedicated to himself. The task was to write a letter to the future to keep note of the achievements realised until that moment and entrust time with dreams and hopes for even better times. The protagonist of this story was a patient, roughly 46 years old, who lived in the smallest town of the Park of Nebrodi (Messina) where he got accustomed to conducting a lonely life. He used to do simple tasks at work. He was one of the guardians of the town cemetery. Salvatore came to my attention following a previous diagnosis of tonsillar carcinoma with an oncological follow up and a less specified form of alcoholism. Once we finished discussing cancer and its psychological implications (fear of relapse and similar), I referred the patient to specialists in pathological addictions. However, after that meeting, the patient’s sister insisted that I should take care of her brother, as he had never felt so welcomed, heard and not judged as he did in our session. They trusted me, but I didn’t believe in my competencies. I was worried about therapeutic failure because I was not an expert in that field and I could not let the patient experience yet another failure, as Salvatore already felt as though he had failed his entire life! The sister did not give up, certain that both of us should accept the challenge.
Fear of making mistakes often leads to walking already beaten paths and obtaining no new result. That’s the time where we tend to demonise our mistakes, both at work and in our personal life. Taking responsibility to accept the risks that come with uncertainty marks the beginning of change. Those who act in the direction of change can come across error, challenging feelings and moments of great difficulty, but can also salvage and give meaning again to their own existence. They learn to overcome obstacles. We accepted that challenge and won in the end.
Fear of making mistakes often leads to walking already beaten paths and obtaining no new result. Luigia Carapezza
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