Discussion
The complex and chaotic nature of healthcare suggests that errors are
unavoidable6. In this context, we studied how
generalist physicians make sense of and grow from medical errors.
Shepherd et al. (2019) describe 4 dimensions of medical education that
can impact what is learned from error: the learning culture,
acknowledging the negative emotions, the tension between individual and
systems responsibilities for error and the saliency of errors from
medical residency training34. In contrast to their
findings, participants in our study shared stories from the distant and
near past and the saliency of errors from residency only was not as
pronounced.
In sports and medicine, no matter how proficient, poised, or skilled the
individual may be, there is still a possibility that an error in
judgement is made or a previously unknown gap in knowledge affects a
decision; either of these which can lead to a near-miss or catastrophic
ending62. When errors happen within a medical culture
and they are not accepted or discussed, physicians become the “second
victim”37. Thus, to complement the steps taken to
minimize errors, there needs to be a continued effort to sustain a
non-threatening medical environment where errors can be discussed openly
and for the overall purpose of learning and improving one’s practice
(e.g., through modelling from healthcare leadership, supportive and
candid coaching from senior physicians, programs that involve patient
perspectives, etc.,). This supportive environment can serve as a vehicle
for physicians in their quest to face the outcome of the error and
embark on an emotional, logistical, and interpersonal journey to learn
from the process. Although there are some major differences in the
cultural and social components of the post-error debriefing process
between medicine and sports, it is important to recognize the benefit
that can be gained through the encouragement of appropriate and accepted
analyses of past errors for the purpose of improving patient safety and
physician wellbeing (e.g., by accounting for feedback reception and its
influencing factors)63.
One of the key components within our meta-narrative is the importance of
the coach-athlete relationship. Within our analysis, we recognize that
the coach-athlete dynamic in sports is represented by a
physician-supervisor dynamic. This is because for most practicing
physicians, a ‘coach’ is often a senior colleague. Furthermore, unlike
sports where the coach can witness performance in real time and blocks
out sustained protected time for an athlete, in medicine, the supervisor
may only get self-reported data, may not always observe performance
directly, fulfills their ‘coach’ duties off the side of their desks, and
divides their loyalty between assessment and advocacy.
This dynamic has been significantly researched in sports due to the
tremendous influence that coaches have on the physical and psychological
development of their athletes. Short & Short (2005) have distilled this
relationship to symbolize the mutual interconnection of the following
components: closeness (based on trust, respect, appreciation),
commitment (interpersonal intentions that maintains the relationship
over time), complementarity (cooperation, responsiveness,
friendliness)64. For this relationship to flourish,
the coach must play a variety of roles that include teacher, organizer,
learner, and friend 63. The coach’s experience, knowledge, access to
resources, and relationship-building skills become key attributes to
successful coach-athlete relationships. When the coach provides
intellectual stimulation and appropriate role
modelling65, it contributes to positive coach-athlete
relationships and the minimization of athlete
anxiety66. Although coaching has existed as a
fundamental component in the fields such as sports, music, lifestyle,
leadership, and business, coaching in medical education has recently
emerged as a valued element of the medical teacher’s
toolbox65-73. Within clinical environments, the
concept of coaching is more poorly defined and there has been little
examination of the transferability of coaching principles from other
fields74. In a study by Watling and LaDonna, three
primary similarities between the philosophies of coaches in the clinical
learning setting, physicians with experience as sports/arts/business
coaches, and sports coaches who did not have a medical background were
identified: 1) a focus on growth and development (goal to ‘unlock human
potential’); 2) continuous reflection; and 3) the embrace of failure as
a catalyst for learning74. Despite the commonalities,
the role of coaching in medicine was ill-defined because: 1) coaching is
often embedded within clinical supervision; 2) the lines between
coaching and other pedagogical roles are blurred; 3) the role between
coach and player are frequently interchangeable. Thus, although our
metaphor illuminates the potential for coaching to catalyze the
conversion of errors to learning, precautions must be taken to identify
meaningful opportunities for this to occur. More pragmatic and
interdisciplinary research is needed to better understand the role of
clinical coaches and how they can be integrated into the medical
curriculum.
Although most generalist physicians who work in teaching hospitals
reported that they typically discuss errors with their colleagues, a
large number also reported that they avoid such conversations due to
fear that their colleagues would not be supportive
listeners75. Therefore, another potential opportunity
for future development could be around training physicians to be
supportive and empathetic colleagues. Because medicine is a field where
professionals are continuously learning, it is important for support
around medical errors to not only occur during official training periods
such as medical school, residency, and fellowship, but throughout one’s
career trajectory. By offering avenues to engage in dialogue, colleagues
and friends can be important sources of support for growth and
development. This change can be achieved in a structured peer support
program 76, formalized continuing professional development discussion
groups where they can discuss their personal performance metrics or
practice patterns77,78, or more informally outside of
the clinical setting79. Health and wellness techniques
tailored for physicians may also serve as avenues to further support
this growth process. In general, contemporary medical education should
focus on establishing a medical learning environment where errors are
recognized rather than denied, and trainees are trusted and supported,
rather than judged76.