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.