MEdIC Series: The Case of the Failure to Fail

failure to fail

Welcome to season 4, episode 8 of the ALiEM Medical Education in Cases (MEdIC) series! Our team (Drs. Tamara McColl, Teresa Chan, John Eicken, Sarah Luckett-Gatopoulos, Eve Purdy, Alkarim Velji and Brent Thoma) is pleased to welcome you to our online community of practice where we discuss the practice of academic medicine!

This month, we present a case of an attending emergency physician who struggles with the ingrained “failure to fail” culture amongst his colleagues when faced with a resident who has significantly underperformed throughout his emergency medicine rotation.

MEdIC: The Case of the Failure to Fail

By Dr. Tamara McColl

Mark walked into the emergency department boardroom for the monthly departmental meeting. He sat down next to his friend Aaron and quickly scanned the meeting agenda. His eyes honed in on item number 3, a discussion of the recent learners who had rotated through the department.

“Hey Aaron, did you work with Trevor this month?”

“Yeah…” Aaron groaned, rolling his eyes.

“I’m definitely going to bring up his performance this month. Far too many red flags. He’s not performing at his level of training at all. Frankly, it’s dangerous to let him work with patients unsupervised!”

Trevor was a first-year surgical resident with whom Mark had worked several shifts earlier in the month. Within a few hours of their first shift, he noticed Trevor’s poor attention to detail, dismissive attitude towards concerning historical features, and very narrow differentials surrounding his cases. Amongst his many clinical missteps he had misdiagnosed a septic joint, planned to discharge a patient with unstable angina, and was overconfident with a central line and inadvertently cannulated the carotid artery.

Mark provided Trevor with honest feedback throughout the rotation and tried to help him progress, but didn’t notice much improvement with subsequent shifts. A big part of the issue was his attitude. He seemed resistant to constructive feedback and was defensive whenever Mark attempted to debrief various mishandled cases. Mark mentioned his concerns about Trevor to several colleagues throughout the month and it seemed like everyone was on the same page regarding his performance.

The meeting progressed quickly and before he knew it, they had reached the topic of resident progression. Dr. Singh went through each resident individually and allowed the group to comment and voice their concerns. When he arrived at Trevor’s name, Mark was shocked.

“I noticed some discrepancy in Trevor’s evaluations. Most of his scores are “meets expectations” and “exceeds expectations” aside from yours, Mark. I see you were the only staff who had some reservations about his performance?” said Dr. Singh, glancing over his folder at Mark.

“Yes, I don’t believe he’s met the objectives of our rotation. I had outlined some specific examples of cases we had together as well as a few critical incidents identified on shift. He’s overconfident and frankly, I believe his practice is unsafe,” Mark replied. “It’s interesting that I’m the only one who raised concerns since a few of us had discussed his performance and it seemed like we all had similar reservations.”

“Well he’s certainly not an all-star like our own residents, but for an off-service resident, he’s fine. We’ve definitely passed residents that were far worse than he is!” joked Dr. Davis, a senior physician in the group.

“Do you know what kind of a process it is to fail a learner? Not worth the hassle! He’ll be someone else’s problem next week.” added Dr. Collins. “Plus, do you really want him on shift again for another month?!”

The room broke out in whispers, chuckles, and smiles. Mark looked over at Aaron, hoping for some support but was met with a dispassionate shrug. The conversation in the room moved onto the next resident and then onto other departmental business. The group had overlooked Trevor’s deficiencies and ultimately stamped a “pass” on his final evaluation.

Discussion Questions

  1. Why do you think the physicians generally scored Trevor’s performance as “meets” or “exceeds” expectations rather than providing feedback consistent with their earlier remarks to Mark?
  2. As a clinician teacher who feels strongly about providing honest feedback and remediating struggling learners, how should Mark approach this situation? Is it worth speaking up again?
  3. Why do we have a general “failure to fail” culture in medicine in which we seem to pass learners who would likely significantly benefit from additional time and remediation? Do you think implementation of competency-based evaluation will change this culture as evaluation becomes more concrete and task based?
  4. What interventions could be implemented that would help make the process of reporting poor learner performance easier for staff physicians?

Weekly Wrap Up

As always, we will post the expert responses and a curated commentary derived from the community responses 2 weeks after the case is published.

This month, our 2 experts are:

  • Dr. Nancy Dudek
  • Dr. Karen Hauer

On June 16,  2017 we will post the curated commentary and expert responses to this case! After that date, you may continue to comment below, but your commentary will no longer be integrated into the curated commentary. That said, we’d love to hear from you, so please comment below!

All characters in this case are fictitious. Any resemblance to real persons, living or dead, is purely coincidental. Also, as always, we will generate a curated community commentary based on your participation below and on Twitter. We will try to attribute names, but if you choose to comment anonymously, you will be referred to as your pseudonym in our writing.

MEdIC Series: The Concept
Inspired by the Harvard Business Review Cases and initially led by Dr. Teresa Chan (@TChanMD) and Dr. Brent Thoma (@Brent_Thoma), the Medical Education In Cases (MEdIC) series puts difficult medical education cases under a microscope. On the last Friday of the month, we pose a challenging hypothetical dilemma, moderate a discussion on potential approaches, and recruit medical education experts to provide “Gold Standard” responses. Cases and responses are made available for download in PDF format – feel free to use them! If you’re a medical educator with a pedagogical problem, we would love for you to get involved in the MEdIC series! Send us your most difficult dilemmas (guidelines) and help the rest of us bring our teaching to the next level.

Author information

Tamara McColl, MD FRCPC MEd(c)

Tamara McColl, MD FRCPC MEd(c)

Associate Editor, ALiEM MEdIC Series
Emergency Physician, St. Boniface Hospital, WRHA
Academic Lead, Educational Scholarship
Department of Emergency Medicine
University of Manitoba

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