The meta-narrative (metaphor, characters, setting, and
plot)
Our analysis illustrates that generalist physicians can make sense of
their errors in a way that encourages growth within the profession, but
only after the experience of an emotional trough, acknowledgement of the
error, and taking ownership of their role in the error (Figure 1).
(INSERT FIGURE 1 HERE).
Applying this trajectory, we developed a metaphor comparing the
experiences of the physician to those of an athlete who plays a
professional team sport. The following meta-narrative will help
contextualize the characters, setting, and main features of the plot.
Characters and setting: The characters of this meta-narrative
include: 1) the elite athlete (the physician who displays confidence,
competence, care, empathy, honesty, and a sense of humour); 2)
spectators (family members observing the physician and his/her
interactions with patients); 3) team coach (typically a trusted senior
clinical colleague or supervisor who is supportive, gives honest
feedback for growth, and provides guidance for emotional development and
improvement to professional practice); 4) veteran teammates (clinical
peers who may be relied on to provide affirmations on the course of
actions or expected to lie to make the protagonist feel better about the
outcome of error); 5) rookie teammates (trainees who are junior to the
physician, who may be able to learn from the story of errors); 6) and
overall team (clinic or hospital). It is important to note that although
the patient is highly regarded, valued, and remembered with great
detail, within this meta-story, they are embedded within the physician’s
experience of their error. This became apparent as physicians often
remembered the event, day, and patient in great detail, frequently
intertwining such details within the context of the clinical situation.
The playing field (clinical setting) is a decision-dense, chaotic space
where frequent, brief, and hurried interactions occur. All of these
interactions exist within rules and regulations that need to be followed
and respected.
The Emergent Meta-narrative: The story plot is based around the
emotional and skills-based maturation of a soccer team composed of a
diversely skilled group of elite players, both veterans and rookies.
This metaphor stems from the growth of the protagonist athlete who
embarks on an emotional and difficult journey to improve their skills
and perception after an error costs the team a significant loss (e.g.,
championship game). The coach, veteran team members, and rookies play
important roles in supporting the maturation process. Furthermore,
although a single player is not solely responsible for the error at
hand, the protagonist, through reflexivity, taking some level of
personal responsibility, serves as the steppingstone to engaging in
strategies that have the potential to support the recovery process.
The plot: Primarily, the plot consists of 5 main components: 1)
the pre-error state; 2) occurrence of the error (which is unknown in the
moment); 3) realization of the outcome; 4) acknowledgement of the error
(reflexivity); 5) post-error maturation and growth within the profession
(Figure 1).
The pre-error state is one where the protagonist has not yet experienced
a self-labelled unforgettable or memorable error in their professional
career. Likened to a decorated athlete committed to perfecting their
skill, this phase was often defined by participants using words such as
‘overconfident’ or ‘not diligent enough.’ For example, one physician
said the following about his pre-error state, “I think that’s a very
common thing as we go through residency. I think you kind of go through
stages, but there is a point somewhere at that transition where you
probably get overconfident” (Participant 001).
Analogized to a set play defined for the protagonist athlete, but an
unexpected change of events prevents them from delivering on the
original plan, these errors often leave a long-lasting imprint on the
athlete. The unexpected change of events could be due to something that
occurs within their own team or due to the actions of the opposing team.
Similarly within a clinical setting, these errors have an unforgettable
nature to them, where it is often burned into one’s memory in a way
where minute details can be recalled about the day of the event (e.g.,
what the patient was wearing, what the weather was like outside, etc.,).
Furthermore, they often occur when there is an unexpected change in the
originally defined course of action; the error is also unknown to the
physician in the moment but leads quickly to an unfavorable patient
outcome.
Likened to the point where the protagonist athlete realizes the team has
experienced a critical loss, the realization of this unanticipated
outcome often leads to an emotional trough (dip in self-perception) due
to one of or a combination of the following sentiments: depression,
confusion, shame, embarrassment, and sadness. When reflecting on the
moment where the error is realized, many participants describe it as
shocking, “you think you’re doing something right and then the rug is
pulled out from underneath you and you quickly realize, ‘oh god, this is
all wrong”’ (Participant 005).
Through the support of others, the protagonist is better able to
acknowledge the error and through reflexivity, take
ownership/responsibility for the outcome. This phase relates to the
athlete’s ability to be reflexive about the error that was made; and the
level of support and collegiality they receive from their team and coach
after the error is made are crucial components that contribute to this
realization. Having a supportive coach and team would help catalyze the
athlete’s growth from the error, whereas a blame culture would regress
their potential for improvement and reinstation of their confidence in
future games. Likened to the clinical environment, this phase is
described by participants as “I felt responsible…”, “Looking
back, I knew I should have done x” or “I had failed to consider that
diagnosis.” The realization sparks the recovery process to emotional
growth and positive changes made to professional practice (e.g.,
building resilience, big picture thinking, newfound diligence, newfound
humility, etc.,). Such adaptations were described as “instilling a
sense of humility…”, “I became more thorough…”, and
“I’ve kind of cognitively put a strategy in place to avoid this in the
future.” Participants also highlighted the importance of mentors and
colleagues, a supportive work environment, and the value in sharing such
stories with others. For example, one participant said, “you have
something that ends up in an outcome like that, and you tend to
internalize it and feel like you’re the only person this has happened to
and your decisions were to blame for this. I think, talking with other
people about it, it was pretty clear that lots of other people had
stories like this. There were lots of other things that contributed to
this bad outcome. So, you know, it helps just kind of knowing you’re not
alone, and that other people have been through this” (Participant 001).
In most of the instances, taking the initiative to be reflexive and
having a supervisor or colleague who offered support and reassurance
catalyzed the growth process. In contrast, the absence of these
approaches toward optimal growth, slowed or halted the recovery process.
This could include supervisors not taking the time, effort, or diligence
to handle errors in a constructive way or the culture of the
clinic/hospital being unsupportive or blaming physicians when errors are
made.
The protagonist athlete may also choose to use their error as an example
to teach junior teammates about their recovery journey, advocate for
regulation changes in the sport, and/or help encourage positive
collegiality through workshops, seminars, or team-building activities.
Likewise within the clinical environment, additional approaches toward
optimal growth include using components of previous errors as teaching
points (e.g., writing and presenting an in-depth lecture on the content
area to junior learners), sharing the emotions of the story with
trainees, supporting avenues for policy change, and contributing to a
medical culture that is eager to empathize with medical error dialogues.
Due to the growth and change associated with the error, the protagonist
will be inclined to view their identity as who they were before the
error and who they have become after the error. It is important to
acknowledge that there are many opportunities that must align for an
error to occur and the course often involves the actions of several
players, although it is the protagonist who takes on the responsibility
of the error. This is represented by the various positions that exist
within a team sport and on a medical team. In line with these major
phases, it is important to consider the typology of each character and
how they can all play a role in the post-error growth of the
protagonist’s career. In sports, if there is meaningful coaching, strong
team spirit, and continuous review of practice, athletes are able to
seek out the necessary supports to improve their game. Likewise, if the
clinical supervisor is able to contribute to a medical culture where
work spaces can be used to share and grow from stories of medical
errors, physicians can feel more encouraged to discuss their strengths
with humility, celebrate accomplishments, be open and honest by asking
what knowledge/skills/expertise they need to develop further, accept
criticism, and continually reassess their own performance. Developing
this culture can also contribute toward easing the implementation of
strategies and practices to improve patient safety.
In the cases where personal responsibility is attributed but support is
not provided by either team coaches, medical supervisors, or colleagues,
there is a deeper emotional trough and delayed progression. This may
include the protagonist being much less enthusiastic about their career
or wanting to leave the profession prematurely. Above all, similar to
how meaningful coaching can help athletes grow from errors by unlocking
further potential, clinical supervisors serve as vital catalysts in
advocating for post-error growth within the profession.