“Remember that patient that you saw? The patient with gastroenteritis? Well they came back with a perforated appendicitis and overwhelming sepsis. Wow, you really dropped the ball didn’t you?” Those wordspossess power, most of the time don’t need to be said, and along with the related clinical experience could havea lasting impact that will influence that particular care team for quite some time. They can shape not only the immediate feelings/perceptions of that particular experience through the second victim phenomenon but can help to form unhealthy negative coping mechanisms and emotions with less job satisfaction and increased feelings of burnout. “Second victims” are health care providers who have been involved with patient adverse events and who subsequently develop difficulty coping with their emotions. This has received much, well-deserved, attention but the interaction of mindset and how it impacts the second victims is yet to be determined. (Suggested reading on Second Victims below).
As educators our learnerswill experiencemistakes, setbacks, fatigue, burnout, bias, adverse events, missed MI, failed airways, unexpected patient deaths, missed fractures, and incorrect diagnoses. They come by many names but it is an inevitable part of our training (and professional life). For many of us in medical education the first time that our residents experience this is in the post-graduate training phase. Not only are they caring for patients (even though supervised) own their own, this may be the first time that many of our very driven, goal oriented, high achievers make a mistake or experience a significant life setback.
Over the past decade interacting with many EM residents at various levels of training I have witnessed many mistakes and setbacks of varying severity and clinical relevance. With time, I have come to embrace these moments as a time to build trust, provide support, listen, and help gain insight into the mindset of the resident. I will admit, when I first became Program Director I dealt with these type of situations in more of a punitive fashion. (“Let’s talk about what you did wrong.”)
The students and residents that we mentor and teach are very gifted and have much more experience with success and accolades than failure. These can represent uncharted waters and will require dedicated time and attention on our part to ensure that these events are approached, understood, and ultimately resolved in the healthiest way possible.
In her book Mindset: The New Psychology of SuccessDr. Carol Dweck discusses how the Mindset of the individual can be a great determinant of their success. She makes the distinction between was is referred to as the ‘Fixed’ vs a ‘Growth’ mindsets. This book and the concepts discussed therein have helped me on numerous occasions to have more meaningful interactions with my students and residents (and Faculty) and has helped me to understand how help our trainees navigate and work through a setback in a much more meaningful way. In the book Dr. Dweck discusses that praising learners for their talent instead of hard work does not build mental toughness or build confidence or help to develop resiliency and can actually be counterproductive. This is albeit a much shorter review and description of the significance of the impact mindset can have during the evaluation and feedback process that is discussed in the book.
I suspect that many of us in medical education might recognize some examples of a Fixed mindset or that pivotal moment when the mindset of the learner is revealed.The defensive pushback encounteredwhen discussing a “miss” or the frustration/anger that is voiced from a learner after critical feedback on an evaluation. If youwitness a learner seeming to give up with this type of feedback of feels that they are “no good” this should be an indication to us of the mindset (at that time) of the learner. This reflects the belief that their intelligence and talent are fixed and no amount of effort or energy can change or improve these qualities.
Producing a growth mindset in your learners (and yourself) will take time and we should also view these tough conversations as a wonderful opportunity to build trust with our learners and demonstrate to them that their intelligence and talent do not determine their worth. The Growth Mindset is one that welcomes challenges and opportunities and the Fixed places more value on praise and accolades. This mindset believes that the most basic qualities of the learner, like talent and intelligence, can be improved upon by dedication and hard work.
After reading existing work on this concept in other fields I have tried to incorporate this into our resident and student curriculum and I expect much more work to come on this in the future. I no longer try “to win” the crucial conversations that I have with my students and residents and simply listen to understand, to make sure that they are listened to and to gain insight into their mindset. We must recognize these times of stress and setbacks as great opportunities to help our learners navigate successfully and part of how we do that is to help identify characteristics of the type of mindset they possess at that time. I have witnessed on many occasions that a learner who at a time displays characteristics of a Fixed Mindset will not internalize feedback as well as the Growth Mindset. The defenses that are ‘up’ prevent the introspection necessary to make the steps to objectively consider the feedback, evaluate the situation, review the event in question, or to discuss that mistake.
|Growth Mindset||Fixed Mindset|
|· I can learn anything I want to.
· I want to challenge myself.
· When I fail, I learn.
· Tell me I try hard.
· My effort and attitude determine everything.
|· I’m either good at it or I’m not.
· When I’m frustrated I give up.
· I don’t’ like to be challenged.
· Tell me I’m smart.
· My abilities determine everything.
- Mindset: The New Psychology of Success. Dweck, C.
- Mira JJ, Lorenzo S, Carrillo I, et al. Interventions in health organisations to reduce the impact of adverse events in second and third victims. BMC Health Services Research. 2015;15:341. doi:10.1186/s12913-015-0994-x.
- Burlison JD1, Quillivan RR, et al. The Effects of the Second Victim Phenomenon on Work-Related Outcomes: Connecting Self-Reported Caregiver Distress to Turnover Intentions and Absenteeism.J Patient Saf. 2016 Nov 2. PMID: 27811593
- Grissinger M. Too Many Abandon the “Second Victims” Of Medical Errors. Pharmacy and Therapeutics. 2014;39(9):591-592.
Citation: Burns B (2017) Setbacks in Medical Education: How Does Mindset Play a Role in Support After a Medical Mistake or Adverse Event?. Emerg Med Inves 2017: J134