The willingness to face criticism is crucial for learning and for becoming an even better doctor. Mistakes must be cultivated, but in the correct way.
Photo: Einar Nilsen
Nobody passes through life without making mistakes, and doctors least of all. Eliminating all mistakes and adverse events from the health services is impossible (1). On the other hand, mistakes are important sources of learning at all levels and stages of the theoretical and practical training of doctors (2). Feedback on performance and behaviour is crucial for appropriate learning. This applies to both the basic and specialist training of doctors and to the supervision of doctors’ clinical practice. All this merits mention at the start of a new academic year and at the publication of the annual education issue of the Journal of the Norwegian Medical Association.
I have taught medical students at the University of Oslo for many years. In recent years, we have let the students – in groups of 6 or 7 – prepare and conduct a teaching session for their fellow students in their third year of study on a pre-defined topic related to dermatology. The objective is for the students to learn how to collaborate and gain experience in retrieving relevant information, planning an educational programme and holding a lecture in front of an audience. In addition, they should of course also learn something about their pre-defined topic. The lecture is followed by feedback, in-depth comments, adjustments and additions provided by a professor. Even though the students prepare well and deliver good presentations, it cannot be denied that opinions have been divided among the students with regard to this concept. Some of the critics have questioned the use of time, pointing out the risk that students may stand at the lectern and present misconceptions that the students in the auditorium might accept as valid. In a recent evaluation session, a student claimed that it would be better if a professor were to hold the lecture and present the correct information, thus preventing the students in the auditorium from wasting time and energy on incorrect presentations.
As I see it, there is nothing better than for students to make mistakes or utter statements revealing that they have failed to fully understand the facts of the matter. If one student has misunderstood something, others will most likely have done the same. Exposure of misconceptions is necessary for correcting them. Therefore, mistakes are not reprehensible as such – on the contrary, they are useful (3). Passive spoon-feeding of facts from teacher to student is inconsistent with good educational principles for learning – to maximise learning, students must take an active part (4).
The recognition of how practice, mistakes and identification of mistakes are important for learning outcomes is the reason that simulation and skills practice are widely used in medical training (5). Simulation involves constructing a situation or a sequence of events, in which the student must relate to events that portray reality as closely as possible. Over the last 10 – 15 years, a number of training centres specially adapted to simulation have been established, including in acute medicine, such as SAFER – Stavanger Acute Medicine Foundation for Education and Research (6). At this centre, doctors, nurses, paramedics and other health personnel undertake realistic simulation exercises that are filmed and later evaluated and discussed. For such a training programme to succeed, it is crucial that feedback is provided in an environment characterised by trust, generosity and openness. Everybody needs to feel confident that all participants share the same objective: to become a better health professional. The course participants must dare to make mistakes, be willing to show their mistakes and be prepared to learn from them. Mistakes should be used as an opportunity to learn.
Doctors can be reported to the Norwegian Board of Health Supervision if they make mistakes in their clinical practice. Complaints from patients, their relatives and others who claim that doctors have made mistakes are assessed at various levels of the Norwegian Board of Health Supervision’s organisation. After an expert assessment has been obtained, the doctor in question receives a note of the decision. Such criticism and reprimand may sometimes be perceived as pontification with the benefit of hindsight from bureaucrats who are out of touch with reality. Although it is easy to go on the defensive, the criticism is rarely totally unfounded. When taking a good look at ourselves and remaining open to criticism, we often need to admit that, well yes, I could have done a better job. I could have done things differently and better. Such an admission may not always come easily to a doctor who is conscientious, ambitious and tenacious (7).
Careful consideration of criticism makes one a better doctor. Even when it feels unfair, it is a source of learning: that being a doctor is difficult, that everybody else may not perceive reality in the same way as I do, that you cannot please everybody, and that the profession of medicine requires a readiness to accept words of abuse, criticism and unfair publicity. Fledgling doctors need to be prepared for this, too. I wish you all success in the upcoming academic year!