Encouraged to Fail: A Novel Approach to Building a Culture of Learning Open Access

The process of learning medicine is inherently taxing on one's ego. Standing in front of peers while senior residents and staff expose potential knowledge gaps is a stressful experience for resident physicians. For many, this is the first time they are subjected to public displays of intellectual vulnerability. How they react to the situation (ie, the learning behaviors that they display) and the culture that residency leaders build around them define the success of these valuable learning opportunities. For residents to realize their potential for personal and professional growth from these experiences, leaders must establish a culture of learning.

Addressing failure must be balanced and measured in a true learning culture. On one extreme, external blame, reprisal, and humiliation are applied to the individual whenever they fail; failure is consequently concealed and both individual and group learning does not occur, resulting in repetitive mistakes. On the other extreme, failure is ignored and unacknowledged, sparing the specific resident an ego bruise. However, individual and group learning will not occur, and the same mistakes are repeated.

Even in a balanced culture, residents should feel a measured sense of personal shame when they fail; this is a positive event for growth. When coupled with self-reflection, personal shame catalyzes personal transformation. Though many theories focus on how to improve learning culture, little research exists on the effect of specific implementable actions. In The Culture Code, Daniel Coyle suggested that the 2 crucial skills needed to develop a strong culture are to “build safety” and “share vulnerability.”¹ 

In July 2019, we developed and implemented a novel concept of a “Failure Board” to provide a forum in which residents share their experiences, offer self- and group reflection, destigmatize mistakes to allow for self-forgiveness, and facilitate support and group learning from others' mistakes. These particular attitudes are directly associated with Accreditation Council for Graduate Medical Education (ACGME) core competencies. The Failure Board is a 6x4-foot white board (cost $175) hung in a common area with 3 simple rules:

1. Describe a mistake you made at work (does not have to be clinical).

2. What did you learn?

3. Write your name.

We developed a detailed 10-item questionnaire focusing on residents' perceptions of learning culture. Relevant issues pertaining to learning culture were identified by reviewing published literature between 2000 and 2019 using PubMed and Scopus. The confidential questionnaire was administered to the entire residency program through an online survey. Then, we introduced the Failure Board during an academic conference attended by all residents. After 2 weeks, the board was full, and residents added new submissions regularly. Old submissions are cleared at the end of each 28-day learning block to allow for continued submissions. After 6 months of use, the survey was repeated to assess changes in resident perceptions.

Forty-five of 46 (98%) residents responded to each survey request. Resident perception at every training level noted an increased culture of support over blame. Additionally, these public displays of vulnerability have not led to feelings of isolation or loss of locus of control of their own education. The Failure Board is best utilized as part of a concerted effort from residency leadership to optimize the learning culture. When a culture exists in which failure is both rewarded with support and viewed as a learning opportunity, residents seek more feedback, thus optimizing the learning environment.

The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of Brooke Army Medical Center, the US Army Medical Department, the US Army Office of the Surgeon General, the Department of the Army, the Department of the Air Force and Department of Defense or the US Government.